key: cord- -qfgoue authors: zaman, anis; zhang, boyu; hoque, ehsan; silenzio, vincent; kautz, henry title: the relationship between deteriorating mental health conditions and longitudinal behavioral changes in google and youtube usages among college students in the united states during covid- : observational study date: - - journal: nan doi: nan sha: doc_id: cord_uid: qfgoue mental health problems among the global population are worsened during the coronavirus disease (covid- ). how individuals engage with online platforms such as google search and youtube undergoes drastic shifts due to pandemic and subsequent lockdowns. such ubiquitous daily behaviors on online platforms have the potential to capture and correlate with clinically alarming deteriorations in mental health profiles in a non-invasive manner. the goal of this study is to examine, among college students, the relationship between deteriorating mental health conditions and changes in user behaviors when engaging with google search and youtube during covid- . this study recruited a cohort of students from a u.s. college campus during january (prior to the pandemic) and measured the anxiety and depression levels of each participant. this study followed up with the same cohort during may (during the pandemic), and the anxiety and depression levels were assessed again. the longitudinal google search and youtube history data were anonymized and collected. from individual-level google search and youtube histories, we developed signals that can quantify shifts in online behaviors during the pandemic. we then assessed the differences between groups with and without deteriorating mental health profiles in terms of these features. significant features included late-night online activities, continuous usages, and time away from the internet, porn consumptions, and keywords associated with negative emotions, social activities, and personal affairs. though further studies are required, our results demonstrated the feasibility of utilizing pervasive online data to establish non-invasive surveillance systems for mental health conditions that bypasses many disadvantages of existing screening methods. globally, mental health problems such as depression, anxiety, and suicide ideations are severely worsened during the coronavirus disease (covid- ) [ [ ] [ ] [ ] , specifically for college students [ , [ ] [ ] [ ] ]. yet, current methods for screening mental health issues and identifying vulnerable individuals rely on in-person interviews. such assessments can be expensive, time-consuming, and blocked by social stigmas, not to mention the reluctancy induced by travel restrictions and exposure risks. it has been reported that very few patients in need were correctly identified and received proper mental health treatments on time under the current healthcare system [ , ] . even with emerging telehealth technologies and online surveys, the screening requires patients to actively reach out to care providers. at the same time, because of the lockdown enforced by the global pandemic outbreak, people's engagements with online platforms underwent notable changes, particularly in search engine trends [ [ ] [ ] [ ] ], exposures to media reports [ , ] , and through quotidian smartphone usages for covid- information [ ] . reliance on the internet has significantly increased due to the overnight change in lifestyles, for example, working and remote learning, imposed by the pandemic on society. the sorts of content consumed, the time and duration spent online, and the purpose of online engagements may be influenced by covid- . furthermore, the digital footprints left by online interactions may reveal information about these changes in user behaviors. most importantly, such ubiquitous online footprints may provide useful signals of deteriorating mental health profiles of users during covid- . they may capture insights into what was going on in the mind of the user through a non-invasive manner, especially since google and youtube searches are short and succinct and can be quite rich in providing the in the moment cognitive state of a person. on one hand, online engagements can cause fluctuations in mental health. on the other hand, having certain mental health conditions can cause certain types of online behaviors. this opens up possibilities for potential healthcare frameworks that leverage pervasive computing approaches to monitor mental health conditions and deliver interventions on-time. extensive researches have been conducted on a population level, correlating mental health problems with user behaviors on social platforms [ , ] , especially among young adolescents. researchers monitored twitter to understand mental health profiles of the general population such as suicide ideations [ ] and depressions [ ] . similar researches have been done with reddit, where anxiety [ ] , suicide ideations [ ] , and other general disorders were studied [ , ] . another popular public platform is facebook, and experiments have been done studying anxiety, depression, body shaming, and stress online [ , ] . however, such studies were limited to macro observations and failed to identify individuals in need of mental health assistance. in addition, it has been shown that college student communities rely heavily on youtube for both academic and entertainment purposes [ , ]. yet, abundant usages may lead to compulsive youtube engagements [ ] , and researchers have found that social anxiety is associated with youtube consumptions in a complex way [ ] . it has been shown that online platforms preserve useful information about the mental health conditions of users, and covid- is jeopardizing the mental wellbeing of the global community. thus, we demonstrate the richness of online engagement logs and how it can be leveraged to uncover alarming mental health conditions during covid- . in this study, we aim to examine whether the changes in user behaviors during covid- have a relationship with deteriorating mental health profiles. we focus on google search and youtube usages, and we investigate if the behavior shifts when engaging with these two platforms signify worsened mental health conditions. we hypothesize that late-night activities, compulsive and continuous usages, time away from online platforms, porn and news consumptions, and keywords related to health, social engagements, personal affairs, and negative emotions may play a role in deteriorating mental health conditions. the scope of the study covers undergraduate students in the u.s. we envision this project as a pilot study: it may lay a foundation for mental health surveillance and help delivery frameworks based on pervasive computing and ubiquitous online data. compared to traditional interviews and surveys, such a non-invasive system may be cheaper, efficient, and avoid being blocked by social stigmas while notifying caregivers on-time about individuals at risk. we recruited a cohort of undergraduate students, all of whom were at least years old and have an active google account for at least years, from the university of rochester river campus, rochester, ny, u.s.a. participation was voluntary, and individuals had the option to opt-out of the study at any time, although we did not encounter any such cases. we collected individual-level longitudinal online data (google search and youtube) in the form of private history logs from the participants. for every participant, we measured the depression and anxiety levels via the clinically validated patient health questionnaire- (phq- ) and generalized anxiety disorder- (gad- ), respectively. basic demographic information was also recorded. there were in total two rounds of data collection: the first round during january (prior to the pandemic) and the second round during may (during the pandemic). during each round, for each participant, the anxiety and depression scores were assessed, and the change in mental health conditions was calculated in the end. the entire individual online history data up untill the date of participation was also collected in both rounds from the participants. figure gives an illustration of the recruitment timeline and two rounds of data collections. all individuals participated in both rounds and were compensated with -dollar amazon gift cards during each round of participation. given the sensitivity and proprietary nature of private google search and youtube histories, we leveraged the google takeout web interface [ ] to share the data with the research team. prior to any data cleaning and analysis, all sensitive information such as the name, email, phone number, social security number, and credit card information was automatically removed via the data loss prevention (dlp) api [ ] of google cloud. for online data and survey response storage, we utilized a hipaacompliant cloud-based secure storing pipeline. the whole study design, pipelines, and survey measurements involved were similar to our previous setup in [ ] and have been approved by the institutional review board (irb) of the university of rochester. the google takeout platform enables users to share the entire private history logs associated with their google accounts, and as long as the account of the user was logged in, all histories would be recorded regardless of which device the individual was using. each activity in google search and youtube engagement logs were timestamped, signifying when the activity happened to the precision of seconds. besides, for each google search, the history log contained the query text input by the user. it also recorded the url if the user directly input a website address to the search engine. for each youtube video watched by the user, the history log contained the url to the video. if the individual directly searched with keyword(s) on the youtube platform, the history log also recorded the url to the search results. in order to capture the change in online behaviors for the participants, we first introduced a set of features that quantifies certain aspects of how individuals interact with google search and youtube. the set of features was calculated for each participant separately. individual-level behavior changes were then obtained by examining the variations of the feature between january to mid-march of (prior to the outbreak) and mid-march to may of (after the outbreak). concretely, we defined features and cut the longitudinal data of each participant into two segments by mid-march, around the time of the covid- outbreak in the u.s and campus lockdown. the two segments spanned . months before and after mid-march, respectively, and data before january was discarded. the same feature was extracted from both segments of data, and the change was calculated. such change was referred to as the behavior shifts during the pandemic and lockdown. figure gives an illustration of data segmentations and feature development pipelines. we defined late-night activities (lna) as the activities happened between : p.m. and : a.m. of the next day, regardless of google search or youtube. for each participant, we counted the numbers of late-night activities before ( ()*+#) ) and after the outbreak ( ()*+#) ), respectively. we then calculated the percentage change of late-night activities and used it as a behavior shift feature: for the rest of the study, any mentioned percentage or relative changes of features were calculated the same way as above. we defined inactivity periods as the periods of time where no google search nor youtube activity was performed. we set a threshold of hours, and we identified all the inactivity periods that were longer than hours for each participant from the online data log. moreover, we looked at how these inactivity periods were distributed across hours. we obtained the mid-point hour mark for each inactivity period: for example, an inactivity period started at p.m. and ended at a.m. has a mid-point of a.m. with normalization, we received a discrete distribution of inactivity period midpoints over the -hour bins. it represented how the time away from google search and youtube of an individual was distributed in a -hour period. such distribution was calculated on the data segments before ( ()*+#) ) and after ( "*$)# ) the outbreak, respectively. figure showcases two normalized inactivity midpoint distributions before and after the outbreak: after the outbreak, most of the inactive periods of participant shifted to later hours of the dawn, which was most likely to be a delay in bedtime; for participant , the morning inactivity moved earlier, and new inactive periods during the afternoon appeared after the outbreak. one possible explanation could be that participant started to take naps after noon, resulting in midpoints around p.m. to estimate the difference before and after the outbreak, we calculated the kldivergence [ ] between the two distributions for each participant: equation . the kl divergence of inactivity distributions before and after the covid- outbreak. the kl-divergence is strictly greater than or equals to , and it equals to only when the two distributions are identical. we defined a short event interval (sei) as the period of time that is less than minutes between two adjacent events. it usually occurs when one is consuming several youtube videos or searching for related content in a roll. we counted the total numbers of short event intervals for each participant before ( ()*+#) ) and after ( "*$)# ) the outbreak, respectively. we calculated the percentage change of sei the same way as equation and used it as a behavioral feature. the linguistic inquiry and word count (liwc) is a toolkit used to analyze various emotions, cognitive processes, social concerns, and psychological dimensions in a given text by counting the numbers of specific words [ ] . it has been widely applied in researches involving social media and mental health. for the complete list of linguistic and psychological dimensions liwc measures, see [ (pp - ) ]. we segmented the data log for each participant by mid-march as two blobs of texts and analyzed the words using liwc: for google search, we input the raw query text; for youtube, we input the video title. we considered the 'personal concerns', 'negative emotion', 'health/illness', and 'social words' liwc dimensions. liwc categorized words associated with work, leisure, home, money, and religion as 'personal concerns'. in the 'negative emotion' dimension, liwc included words related to anxiety, anger, and sadness. whereas, in the 'social words' dimension, liwc included family, friends, and gender references. the liwc output the count of words falling in each dimension among the whole text. we quantified the shift in behavior by calculating the percentage change of words in each dimension after the outbreak. we labeled each google search query with a category using the google nlp api [ ]. we utilized the official youtube api to retrieve the information of videos watched by the participants, including the title, duration, number of likes and dislikes, and default youtube category tags. for a comprehensive list of google nlp category labels and default youtube category tags, please refer to [ , ]. there were several categories overlapping with the liwc dimensions, such as 'health' and 'finance', and we regarded the liwc dimensions as a more well-studied standard. instead, we focused on the number of activities belonging to the 'adult' and 'news' categories, which were not presented in the liwc. we calculated the relative changes of activities in these two categories as the behavior shifts for each participant, the same as equation . there were in total scalar continuous dependent variables measuring various aspects of the changes in online behavior for each participant, as defined above. these variables were extracted from two segments of the online data logs, namely the data before and after the pandemic outbreak. for the inactivity periods, the measurement was the kl-divergence between inactivity distributions. for the rest behavioral features, the measurements were all in percentage changes. for both rounds of the data collection, anxiety levels were assessed using the gad- survey, and depression levels were assessed using the phq- survey. with two rounds of surveys reported before and after the outbreak, the change in mental health conditions of each participant was obtained. according to [ , ] , an increase greater than or equals to in the gad- score may be clinically alarming. therefore, individuals with an increase ³ in gad- scores were labeled as the anx group; the rest were labeled as the non-anx group. similarly, as stated in [ ] , an increase greater than or equals to in the phq- score may indicate the need for medical interventions. hence, individuals with an increase ³ in phq- scores were labeled as the dep group; the rest were labeled as the non-dep group. besides the online data and mental health surveys, we also collected basic demographic information such as school year, gender, and nationality. before any analysis of mental health conditions, in order to eliminate the possibility of annual confounding factors interfering with the shifts in online behaviors, twotailed paired independent t-tests were performed. we inspected that, in terms of the five quantitative features, whether the online behavior changes happened every year, such as due to seasonal factors, or only during covid- for the whole study population. as mentioned above, we collected the entire google history log back to the registration date of the google accounts of all participants. thus, we computed the online behaviors changes in both and for all participants, spanning . months before and after the mid-march of each year. the behavior changes were dependent between and for the same participant. viewing the cohort as a whole and measured twice, two-tailed paired independent t-tests were performed on all behavior features. for the main experiment, chi-square tests were first performed to investigate the differences in demographics: school year, gender, and nationality. after that, analyses of covariance were conducted to explore the discrepancy between the dep and non-dep groups with each of the online behavior features while controlling significant demographic covariates. the same was performed between the anx and non-anx groups. notice that, in this observational study, the independent variable was the binary group, i.e., whether or not the individual had a significant increase in the gad- (or phq- ) score. the dependent variables were the behavior changes extracted from the longitudinal individual online data. experiments were carried out in a one-on-one fashion: anxiety or depression condition was the single independent variable, and one of the online behavior changes was the single dependent variable each time. since multiple hypotheses were tested and some dependent variables might be moderately correlated, a holm's sequential bonferroni procedure was performed with an original significance level a= . to deal with the family-wise error rates. we recruited (n= ) participants in total, and all of them participated in both rounds of the study (response rate= %). on average, each participant made , ( % ci , . - , . ) google searches and , ( % ci , . - , . ) youtube interactions from january to march th , and ( % ci , . - , . ) google searches and ( % ci , . - , . ) youtube interactions from march th to the end of may. of the participants, % (n= ) of them reported an increase in the phq- score ³ (the dep group); % (n= ) of them reported an increase in the gad- score ³ (the anx group). % (n= ) of the participants belonged to the anx and dep group simultaneously. of the participants, % (n= ) of the them were female; % (n= ) of the them were male; the rest % (n= ) reported non-binary genders. first and secondyear students occupied % (n= ) of the whole cohort, and the rest were third and fourth-year students (n= ). % (n= ) of the participants were u.s. citizens, and the rest (n= ) were international students. a complete breakdown of demographics and group separations are given in table . the two-tailed paired independent t-tests mentioned at the beginning of statistical analysis was designed to rule out seasonal factors in online behavior changes but focus on covid- before any of the main experiments, and they reported p<. for all quantitative features. hence, the presence of annual or seasonal factors accountable for online behavior changes was neglectable, and it was safe to carry out the following main experiment. this is consistent with one of the main conclusions in [ ] that, when comparing the longitudinal data between different years, behaviors during covid- shifted drastically. for each group (anx, non-anx, dep, and non-dep), the average percentage changes in late night activities, short event intervals, liwc attributes, and google search and youtube categories were all positive increases. analyses of covariance were performed to investigate the online behavior differences between the dep and the non-dep groups, ruling out the gender factor. we dummy-coded the categorical gender factor as a continuous covariate. for late night activities, the dep group (mean= . %, % ci . %- . %) had a higher relative increase than the non-dep group (mean= . %, % ci . %- . %), and a significant difference was found (p=. figure shows the distributions of the percentage increases in online behavior features except for the inactivity divergence in the two groups. similar trends were found between the anx and non-anx groups, partially due to the overlapping with the dep and non-dep populations. for late night activities (p=. , !"#$%"& ' = . , f , = . ), the anx group (mean= . %, % ci . %- . %) had a higher percentage increase than the non-anx group (mean= . %, % ci . %- . %). for inactivity periods (p=. , !"#$%"& ' = . , f , = . ) , the anx group (mean= . , % ci . - . ) had a lower divergence, i.e., fewer alterations in the pattern of inactive periods in a -hour period, than the non-anx group (mean= . , % ci . - . ). the anx group (mean= . %, % ci . %- . %) had more increase in short event intervals than the non-anx group (mean= . %, % ci . %- . %), and a significant difference was found (p=. , !"#$%"& ' = . , f , = . ). for the liwc attributes, the anx group (mean= . %, % ci . %- . %) had a higher relative increase in 'personal concern' keywords than the non-anx group (mean= . %, % ci . %- . %), and this difference was statistically significant (p=. , !"#$%"& ' = . , f , = . ). we found a similar result for 'negative words' (p=. , !"#$%"& ' = . , f , = . ) where the anx group (mean= . %, % ci . %- . %) had higher usages than the non-anx group (mean= . %, % ci . %- . %). 'health/illness' (p=. = . , f , = . ) content showed any significant group difference. for more details, see table . figure shows the distributions of the percentage increases in online behavior features except for the inactivity divergence in the two groups. in this study, we collected longitudinal individual-level google search and youtube data from college students, and we measured their anxiety (gad- ) and depression (phq- ) levels before and after the outbreak of covid- . we then developed explainable features from the online data logs and quantified the online behavior shifts of the participants during the pandemic. we also calculated the change in mental health conditions for all participants. our experiment examined the differences between groups with and without deteriorating mental health profiles in terms of these online behavior features. to the best of our knowledge, we are the first to conduct observational studies on how mental health problems and google search and youtube usages of college students are related during covid- . our results showed significant differences between groups of college students with and without worsened mental health profiles in terms of online behavior changes during the pandemic. the features we developed based on online activities were all explainable and preserved certain levels of interpretability. for example, the short event intervals and inactivity periods measured the consecutive usages and time away from google search and youtube, which were inspired by previous studies on excessive youtube usages [ ] , internet addictions [ ] , and positive associations with social anxiety among college students [ ] . our results indicated that individuals with meaningful increasing anxiety or depressive disorders during the pandemic tended to have long usage sessions (multiple consecutive activities with short time intervals) when engaging with google search and youtube. moreover, anx and dep individuals tended to maintain their regular time-awayfrom-internet patterns regardless of the lockdown as the kl-divergence was low. one possible reason could be that depressed people tend to spend more time at home as regular lifestyles [ , ] , and thereby, after the lockdown, the living environment did not alter much. we further found that the majority of the inactivity periods longer than hours had midpoints around to a.m. for all individuals, which were most likely to be the sleeping period. well-established previous researches stated that depressed individuals have more disrupted sleeping patterns and less circadian lifestyles [ , , ], but they are not validated for special periods such as covid- . we instead focused on comparing the distributions of time away from google before and after the outbreak of covid- , and we had an emphasis on the behavior changes of groups with and without worsened mental disorders. besides, the increase in late night activities corresponded with previous studies in sleep deprivation and subsequent positive correlations with mental health deteriorations [ , ] . our results demonstrated that individuals with significant worsened anxiety or depressive symptoms during the pandemic were indeed likely to stay up late and engage more online. the above three features captured the temporal aspects of user online behaviors, and they have shown statistically significant differences between groups. additionally, our analysis found that there was a significant difference in the amount of adult and porn consumption between individuals with and without worsening depression, which adheres to previous findings that people suffering from depression and loneliness are likely to consume more pornographies [ , . these attributes captured the semantic aspect of user online behaviors. the prevalence of personal affair, social activity, and negative keywords as well as porn consumption have shown statistically significant differences between groups. many researchers have reported that there has been a significant boost in health and news-related topics, at the population level, in various online platforms during covid- . this is partly due to additional measures taken by individuals, various stakeholders, and agencies with regards to preventive measures [ , , ], daily statistics [ , , ], and healthcare (mis)information [ , , ], however, unlike many, our investigation was carried out considering individual-level google search and youtube engagement logs, and our analysis did not reveal any significant spikes in 'news' and 'health/illness' category between the groups of individuals with deteriorating anxiety and depression during the pandemic. one possible explanation for such observation can be due to the target population (college students) of our study who may prefer to follow news from other popular platforms such as social media. finally, covid- has shaken the foundation of human society and forced us to alter daily lifestyles. the world was not ready for such a viral outbreak. since there is no cure for covid- , it, or an even more deadly viral disease, may resurface at different capacities in the near future. society may be forced to rely on technologies even more and employ remote learning, working, and socializing for a longer period of time. it is important that we learn from our experience of living through the initial covid- outbreak and take necessary measures to uncover the changes in online behaviors, investigating how that can be leveraged to understand and monitor various mental health conditions of individuals in the least invasive manner. furthermore, we hope our work paves the path for technology stakeholders to consider incorporating various mental health assessment monitoring systems using user engagements, following users' consent in a privacy-preserving manner. they can periodically share the mental health monitoring assessment report with respective users based on their online activities, education, and informing users about their current mental health. this can eventually encourage individuals to acknowledge the importance of mental health and take better care of themselves. first, while most of the online behavioral features we developed showed significant differences between groups of students with and without deteriorating anxiety and depressive disorders during covid- , our study cohort only represented a small portion of the whole population suffering from mental health difficulties. therefore, further studies are required to investigate if the significant behavioral changes still hold among more general communities, not limiting to college students. nonetheless, we argue that the explainable features we constructed, such as late-night activities, continuous usages, inactivity, pornography, and certain keywords, can remain behaviorally representative and be applied universally across experiments exploring the relationship between mental health and online activities during the pandemic. second, in this work, we studied the relationship between user online behaviors and the fluctuations in mental health conditions during covid- . any causal relationship between online behavior and mental disorders is beyond the scope of this work. as one can readily imagine, online behavioral changes could both contribute to or be caused by deteriorating anxiety or depressive disorders. moreover, though we included preliminary demographic information as covariates, there remains the possibility of other confounding factors. in fact, both the shifts in online behaviors and deteriorating mental health profiles may be due to common factors such as living conditions, financial difficulties, and other health problems during the pandemic. nor there was any causal direction implied between covid- and online behavior changes, which was introduced in the first paragraph of statistical analysis as a precaution before the main experiments. albeit a pilot study, our results indicated that it is possible to build an anxiety and depression surveillance system based on passively collected private google data histories during covid- . such non-invasive systems shall be subject to rigorous data security and anonymity checks. necessary measures need to be in place to ensure personal safety and privacy concerns when collecting sensitive and proprietary data such as google search logs and youtube histories. even in pilot studies, participants shall preserve full rights over their data: they may choose to opt-out of the study at any stage and remove any data shared in the system. moreover, anonymity and systematic bias elimination shall be enforced. as an automatic medical screening system based on pervasive data, it has been extensively studied that such frameworks are prone to implicit machine learning bias during data collection or training phases [ [ ] [ ] [ ] . black-box methods should be avoided as they are known to be vulnerable to adversarial attacks and produce 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clinical safety potential biases in machine learning algorithms using electronic health record data a systematic review of machine learning models for predicting outcomes of stroke with structured data exploiting the vulnerability of deep learning-based artificial intelligence models in medical imaging: adversarial attacks understanding adversarial attacks on deep learning based medical image analysis systems. pattern recognition this research was supported in part by grant w nf- - - and w nf- - - with the us defense advanced research projects agency (darpa) and the army research office (aro). we acknowledge the contributions by michael giardino, adira blumenthal, and ariel hirschhorn at the beginning phase of the project. key: cord- -r teblhs authors: dibenigno, julia; kerrissey, michaela title: structuring mental health support for frontline caregivers during covid- : lessons from organisational scholarship on unit-aligned support date: - - journal: nan doi: . /leader- - sha: doc_id: cord_uid: r teblhs background: although the covid- pandemic exposes frontline caregivers to severe prolonged stresses and trauma, there has been little clarity on how healthcare organisations can structure support to address these mental health needs. this article translates organisational scholarship on professionals working in organisations to elucidate why traditional approaches to supporting employee mental health, which often ask employees to seek assistance from centralised resources that separate mental health personnel from frontline units, may be insufficient under crisis conditions. we identify a critical but often overlooked aspect of employee mental health support: how frontline professionals respond to mental health services. in high-risk, high-pressure fields, frontline professionals may perceive mental health support as coming at the expense of urgent frontline work goals (ie, patient care) and as clashing with their central professional identities (ie, as expert, self-reliant ironmen/women). findings: to address these pervasive goal and identity conflicts in professional organisations, we translate the results of a multiyear research study examining the us army’s efforts to transform its mental health support during the wars in iraq and afghanistan. we highlight parallels between providing support to frontline military units and frontline healthcare units during covid- and surface implications for structuring mental health supports during a crisis. we describe how an intentional organisational design used by the us army that assigned specific mental health personnel to frontline units helped to mitigate professional goal and identity conflicts by creating personalised relationships and contextualising mental health offerings. conclusion: addressing frontline caregivers’ mental health needs is a vital part of health delivery organisations’ response to covid- , but without thoughtful organisational design, well-intentioned efforts may fall short. an approach that assigns individual mental health personnel to support specific frontline units may be particularly promising. abstract background although the covid- pandemic exposes frontline caregivers to severe prolonged stresses and trauma, there has been little clarity on how healthcare organisations can structure support to address these mental health needs. this article translates organisational scholarship on professionals working in organisations to elucidate why traditional approaches to supporting employee mental health, which often ask employees to seek assistance from centralised resources that separate mental health personnel from frontline units, may be insufficient under crisis conditions. we identify a critical but often overlooked aspect of employee mental health support: how frontline professionals respond to mental health services. in highrisk, high-pressure fields, frontline professionals may perceive mental health support as coming at the expense of urgent frontline work goals (ie, patient care) and as clashing with their central professional identities (ie, as expert, self-reliant ironmen/women). findings to address these pervasive goal and identity conflicts in professional organisations, we translate the results of a multiyear research study examining the us army's efforts to transform its mental health support during the wars in iraq and afghanistan. we highlight parallels between providing support to frontline military units and frontline healthcare units during covid- and surface implications for structuring mental health supports during a crisis. we describe how an intentional organisational design used by the us army that assigned specific mental health personnel to frontline units helped to mitigate professional goal and identity conflicts by creating personalised relationships and contextualising mental health offerings. conclusion addressing frontline caregivers' mental health needs is a vital part of health delivery organisations' response to covid- , but without thoughtful organisational design, well-intentioned efforts may fall short. an approach that assigns individual mental health personnel to support specific frontline units may be particularly promising. the covid- pandemic has unleashed extraordinary stresses on frontline caregivers, from personal exposure risk and fears of infecting loved ones to extreme and unfamiliar workloads while facing moral dilemmas and intense suffering in patient care. healthcare organisations' ability to support frontline caregivers' mental health needs is widely considered essential as the pandemic draws ongoing waves of critically ill patients to their doors. however, the call to care for others often eclipses caregivers' attention to their own well-being, and even under typical circumstances, they suffer from high rates of burnout, stress, trauma and suicide. these challenges are amplified by the pandemic; for instance, a survey of covid- caregivers in china found that % reported distress; % reported depression; and % reported anxiety. healthcare organisations report that traditional approaches to supporting employee mental health, such as employee assistance programmes, are falling short under the present crisis conditions. yet, there has been little clarity on why this is the case and what alternatives may be better. translating findings from organisational scholarship on professionals working in organisations during rapid change, this paper informs the vital question of how to support professional caregivers' mental health needs by elucidating professionals' reactions to organisationally sponsored mental health services. organisational scholarship has demonstrated how professionals experience goal and identity conflicts that undermine frontline professional cooperation with organisational support efforts. frontline leaders and workers, especially in fields characterised by high stress and high risk, may perceive mental health supports as distracting from all-consuming frontline work goals (ie, patient care) and as going against their valued professional identities (ie, as expert, self-reliant ironmen/women). because most traditional organisational mental health structures put the onus on employees to seek help and separate mental health personnel from frontline units, they neglect to create opportunities to develop the familiarity and contextualised awareness between mental health personnel and frontline units that can help to align seemingly conflicting goals and bridge identity differences. without attention to these critical issues-and intentional efforts to design mental health offerings that address them-well-intended efforts to meet caregivers' mental health needs during covid- are likely to fall short. this paper proceeds in three parts. first, we synthesise organisational research on professionals in organisations to articulate how goal and identity conflicts arise within organisations and elucidate why these conflicts can undermine well-intended organisational efforts to support professionals during a crisis. second, we describe findings from a major multiyear ethnographic research study examining an effort to deliver mental health support in a professional arena with strong parallels to healthcare during covid- : the us army during the wars in iraq and afghanistan. this in-depth translation of a research study in a parallel context illustrates the problems that professional goal and identity conflict can pose for providing crisis-related mental health support and surfaces an alternative approach that is rooted in research and theory on organisational design. third, we discuss the implications of the army study for healthcare organisations and highlight the potential for skilful organisational design to help address goal and identity conflicts by assigning mental health personnel to support specific frontline units. these lessons from organisational scholarship and the us army's experience provide critical insight into how healthcare organisations can structure mental health support for frontline caregivers during covid- . scholarship on professionals in organisations elucidates two important barriers to the use and effectiveness of employee mental health support during crises: goal conflict and identity differences between frontline units and professional mental health personnel, described in detail as follows. classic organisational scholarship finds goal conflict is endemic within organisations, as specialised units and different professional groups often have their own interests and prioritise their own goals which may conflict. [ ] [ ] [ ] even when shared organisational goals exist, such as to support the mental health of an organisation's workforce while ensuring quality service delivery, entrenchment in one's own group's perspective from their professional training and position in the organisational structure can make shared goals difficult to achieve. this can lead to regular conflict between frontline units and members of professional groups brought in to support them, leading to suboptimal outcomes. when implementing mental health support in frontline healthcare environments, perceptions of goal conflict are reasonable to expect. both frontline unit leaders and staff may view mental health support as detracting from patient care goals; for example, research in surgery finds perceptions of a zero-sum conflict between being 'ironmen' who are fully dedicated to patient care / and complying with wellness-oriented interventions that limit work hours to promote sleep and prevent burnout. such goal conflicts are likely further heightened in a crisis that accentuates time constraints, as covid- has done. taking time away from care delivery for mental health may be seen as creating further team burdens on the unit, a common saying within healthcare being 'if you are not rounding, you are being rounded on', implying the only acceptable excuse for not providing patient care is becoming a patient oneself. by contrast, in line with their own professional training, mental health personnel may prioritise the mental health needs of caregivers over frontline units' near-term patient care goals. organisational research has identified a number of mechanisms through which goal conflict can be addressed. these include, for example, establishing formal rules and guidelines for interaction across groups ; establishing cross-functional teams, task forces and departments ; implementing collaborative incentives ; and deploying colocation or matrix structures. these mechanisms rationally rely on the idea that better aligning goals through rules, incentives and authority structures will be sufficient to bridge goal conflicts; however, many conflicts in organisations have proven immune to such rational attempts at goal alignment. when there are deeply held differences in identities between groups-as there likely are between those on frontline units and mental health support personnel-such rational mechanisms can prove ineffective. identity differences between professional groups and departmental units within organisations can exacerbate goal conflicts, making them heated and personal. identity refers to how a group collectively defines 'who they are', including their distinctive values, beliefs and sense of what being a good-standing member entails, and they are often apparent in members' common dress, language and demeanour. identity differences are prevalent across professional groups, for whom 'who they are' (their professional identity) is intimately connected with 'what they do' as professionals. professional group members are often especially committed to advancing goals congruent with their strongly held professional identities. for example, in many healthcare specialties, training and culture prize professional identities in which one is tough, desensitised and self-reliant in response to traumatic situations. these qualities are largely considered part of being a good professional caregiver, what has been described as the 'historic "iron doc" culture' of medicine. such professional identities run counter to identities associated with mental health professionals as supporting vulnerability and seeking help. the prevalent labeling of frontline caregivers as 'heroes' as they serve amid covid- may further buttress this identity, perhaps making it even harder to overcome the stigma of admitting a need for support and to relate positively with mental health personnel. because identity runs deep in individuals, goal conflicts arising across groups with different identities can be difficult to ameliorate through rational means alone. for example, research has documented how inviting physician and hospital administrator groups prioritising different goals (eg, providing quality patient care and managing a profitable hospital) to a strategic planning retreat without addressing identity differences can backfire and further fuel their conflict. similarly, because there are likely identity differences between mental health personnel and frontline caregivers, particularly those in emergency and intensive care units known for their stoicism amid trauma, there is potential that mental health resources go underused and underappreciated because they are considered out of touch with the realities of frontline units' unique professional identities. in sum, organisational scholarship on professionals in organisations suggests goal conflict and identity differences between mental health and frontline caregiver professional groups may pose substantial barriers to the use and usefulness of mental health support during covid- . with goal and identity conflict posing stark challenges to providing mental health services to frontline professionals, integrative solutions that equip organisations with practical strategies to address conflicting goals and identity differences are vital. to shed light on potentially useful strategies for structuring mental health support during covid- , we further describe findings from a major multiyear ethnographic research study conducted from to examining an effort to deliver mental health support in a professional arena with strong parallels to healthcare during covid- : the us army during the wars in iraq and afghanistan. [ ] [ ] [ ] [ ] [ ] translating research and evidence us army case: anchored personalisation during the wars in iraq and afghanistan, the us army sought to transform its mental health services to better support soldiers' needs, given increased rates of post-traumatic stress disorder and suicide. however, much like healthcare workers during covid- , soldiers in the us army faced the dual challenge of prolonged periods of high personal risk and stress, combined with intense demands to be 'field ready' and 'tough. in-depth research examining army brigades and mental health clinics over time (through over in-depth interviews and hours of on-site observation) indicated that most traditional mental health support initially went underused, due to many of the professional goal and identity issues described earlier. mental health support provoked resistance from soldiers' supervisory commanders, who often discouraged soldiers from using mental health services, fought treatment recommendations (eg, to allow a soldier to sit out of a stressful training exercise) and emphasised long-standing prejudices about mental health personnel (eg, calling them 'berkeley hippies'). meanwhile, mental health personnel, stereotyping commanders as 'bullies', remained removed from soldiers' unique units and work environments, and made recommendations often considered inappropriate for valued mission-readiness goals or unnecessarily damaging to soldier career aspirations. however, this research also uncovered an alternative approach that resolved the pervasive and long-standing goal and identity conflicts between mental health support and frontline unit supervisors and members. rather than providing centralised resources that soldiers were expected to proactively seek out, a dedicated mental health clinician was assigned to work specifically with a few frontline units. this was the structure ultimately implemented across the us army after experimenting with numerous other structures. - this approach enabled what is called 'anchored personalisation'. 'personalisation' occurred as mental health personnel developed personalised relationships and familiarity with the frontline unit members and leaders they were assigned to support. this both helped mental health personnel to customise the support they offered to suit the unique needs of individuals in their specific units and to reduce the stigma supervisory commanders and soldiers attached to mental health services that ran counter to their selfreliant 'warrior' identities. in working with and learning about specific units, mental health personnel were able to design support that was sensitive to the specific mental health needs of soldiers in their units, as well as their career aspirations and unit goals (eg, discretely assigning a soldier to a less stressful role during a training exercise). because these mental health personnel saw patientsoldiers in the same units, they also learned about unit-level issues that helped them tailor supports. making mental health personnel accountable for learning about the unique needs of their assigned units spurred them to devise support that resonated with rather than conflicted with frontline professional identities. in so doing, feelings of stigma began to change; for example, using mental health services started being framed as 'a sign of strength' or 'being man enough to get help', which aligned with the professional identities of many in all-male combat units. at the same time, this approach ensured this personalisation was balanced by 'anchoring', in which the mental health personnel who were assigned to different units regularly came together, helping one another remain anchored in their professional goals of supporting mental health and resist the demands of frontline units' leadership that sometimes ran counter to soldier well-being. the concept of anchored personalisation for mental health support provision is rooted in organisational scholarship on personalisation. research on personalisation, defined as regular, individuated one-on-one contact across groups, has been found to reduce intergroup stereotyping and lead to increased perspectivetaking as members of different groups develop familiarity with and knowledge about one another as people rather than stereotypes in a variety of contexts. such perspective-taking can enable people to break out of their entrenched worldviews to find integrative solutions that are win-win for both groups. however, personalisation can also become problematic if personalised contact with the other group leads to co-optation and indoctrination into the other group's perspective, a phenomenon exhibited among bankers through 'regulatory capture' and affirmative action officers protecting their organisations over advocating for employees. it is for this reason that maintaining an anchoring contact with one's home group is vital for mitigating risks of co-optation when personalisation transpires. although there are certainly differences between professional soldiers who train to endure prolonged traumatic situations at war and frontline caregivers suddenly confronting unexpected traumatic situations brought by the covid- pandemic, there are two central insights from the us army's experience structuring mental health support that are especially relevant for the challenge of providing mental health support for frontline caregivers. first, if personalisation is vital to breaking down barriers to mental health across professional differences, then relying on it to happen by chance is likely insufficient, particularly in high-risk, high-pressure fields like the military and healthcare. because organisational structures shape the types of interactions members have with others inside their organisations, when properly designed, the right structures can offer opportunities for regular interaction, familiarity and personal relationships between members of the organisation outside one's home group. in healthcare, organisational design is a critical lever for structuring and institutionalising effective care delivery. intentional organisational design may be a key lever through which healthcare organisations can ensure mental health offerings achieve their intended impact. the second central insight emerging from the us army case is that the specific strategy of assigning mental health personnel to a few specific frontline units may be particularly advantageous. because it enables anchored personalisation, this strategy may help mitigate goal conflict and identity challenges related to mental health support usage in healthcare, such as limited time and a culture of 'toughing it out', that make mental health resources so difficult for caregivers to seek out and use in practice. if unit staff, and particularly unit leaders, become more familiar with a dedicated mental health support person through personalised interactions, together they can break down stigma and stereotypes, take one another's perspectives and become partners in jointly devising contextualised ways of supporting unit staff well-being that are customised and minimally disruptive to patient care. doing so may also help personnel frame mental health services in ways that resonate with specific units to encourage use, such as by relabeling mental health as 'psychosocial support' or 'resiliency coaching', or by tapping into the self-sacrificing identity of many caregivers through emphasising how use of mental health support may enable sustained high quality care for patients. customisation of mental health support is particularly critical because the specific stresses brought on by covid- vary across translating research and evidence different departments and units. for example, the mental health needs of a covid- intensive care unit with nurses isolated behind closed doors with gravely ill patients may differ from those of emergency department staff interacting with large numbers of patients whose covid- status may yet be unknown. in addition, time constraints across units vary; for example, especially busy units may require more proactive identification of who needs help, such as from assigned peer 'buddies' or leaders, while others may require daily decompression huddles with their assigned mental health personnel purposefully making themselves available afterward to do one-on-one follow-ups. at the same time, ensuring mental health personnel maintain connection with those in similar roles serving other units can help them stand firm on the importance of supporting mental health goals, even when time demands and the culture of medicine may default to relegating mental health back to the sidelines. addressing caregivers' mental health needs is a vital part of health delivery organisations' response to the covid- crisis, but without thoughtful organisational design, even wellintentioned efforts may fail. organisational research elucidates how goal and identity conflict can undermine such efforts in professional organisations and has explored possible solutions that can be built into the design of mental health support. based on findings from a in-depth study of the us army's evolution of its mental healthcare support for frontline units, a design that assigns individual mental health personnel to support specific frontline units may be particularly promising during covid- . because it enables anchored personalisation, this design can help professional caregivers and mental health personnel bridge their differences and devise innovative solutions that increase the use and usefulness of mental health support. implementation of versions of anchored personalisation in response to covid- is already occurring, with examples in systems such as university of california's zuckerberg san francisco general hospital and yale new haven hospital. these and related efforts to thoughtfully apply organisational structures to better support caregiver mental health will remain vital as the early crisis fades, but the pressure on frontline caregivers endures and resurfaces as the pandemic continues. perhaps such efforts will also help revitalise how mental health, stress, trauma exposure and burnout are addressed in healthcare delivery, even after this crisis, to better support the frontline caregivers who serve patients day after day. understanding and addressing sources of anxiety among health care professionals during the covid- pandemic preventing occupational stress in healthcare workers factors associated with mental health outcomes among health care workers exposed to coronavirus disease all hands on deck: how uw medicine is helping its staff weather a pandemic a behavioral theory of the firm managing intractable identity conflicts multiple and competing goals in organisations: insights for medical leaders explaining the selection of routines for change during organizational search challenging operations: medical reform and resistance in surgery antecedents and consequences of project team 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managers post-traumatic stress innovations final report: transforming the psychological health system of care in the us military transformation of the us army behavioral health system of care: an organizational analysis using the 'three lenses transformation of mental health care for u.s. soldiers and families during the iraq and afghanistan wars: where science and politics intersect the application of the personalization model in diversity management caught in the revolving door: firm-government ties as determinants of regulatory outcomes legal ambiguity and the politics of compliance: affirmative action officers' dilemma structural contexts of opportunities team scaffolds: how mesolevel structures enable rolebased coordination in temporary groups the necessity of others is the mother of invention: intrinsic and prosocial motivations, perspective taking, and creativity we are grateful to the healthcare leaders and frontline caregivers working during the covid- pandemic for whom we hope this article will be of service to. we also thank amy wrzesniewski and marissa king for reading a prior version, amit nigam for his encouragement to write this translation piece, and the bmj leader editorial team for thier rapid turnaround of this work. the views and conclusions contained herein are those of the authors and do not necessarily reflect the views of the us government or us army. contributors jdib and mk played an equal role in conceptualising and writing this article.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.competing interests none declared. key: cord- -ocpehls authors: im, hyojin; swan, laura e. t. title: capacity building for refugee mental health in resettlement: implementation and evaluation of cross-cultural trauma-informed care training date: - - journal: j immigr minor health doi: . /s - - -w sha: doc_id: cord_uid: ocpehls refugee mental health needs are heightened during resettlement but are often neglected due to challenges in service provision, including lack of opportunities for building capacity and partnership among providers. we developed and implemented culturally-responsive refugee mental health training, called cross-cultural trauma-informed care (cc-tic) training. we evaluated cc-tic, using a free listing and semi-structured retrospective pre- and post-training evaluation with five localities in two states in the u.s. the results showed significant improvement in providers’ knowledge of trauma impacts, cultural expressions of trauma/stress-related symptoms, and culturally-responsive trauma-informed care. trauma-informed care specific to refugee resettlement was regarded as the most helpful topic and community partnership building as the most requested area for future training. this study emphasizes that culturally-responsive trauma-informed approaches can help bridge gaps between mental health care and resettlement services and promote exchanges of knowledge and expertise to build collaborative care and community partnership. refugees commonly experience trauma, such as social conflicts and violence, witnessing tragic deaths, torture, forced confinement, and numerous human rights violations [ ] [ ] [ ] , which likely increases risk for various mental health issues and disorders [ , ] . in fact, more than one in four refugees who have been exposed to mass conflict report posttraumatic stress disorder (ptsd), and more than one in four report symptoms of major depressive disorder [ ] . in a recent review [ ] , asylum seekers and refugees reported high rates of depression, anxiety, and ptsd (all up to %), despite variation across settings (e.g., displacement or resettlement, high-or low-income countries). in addition, psychiatric disorders are notable when assessment includes mental illness beyond common mental disorders. in a german study with refugees from syria, iraq, and afghanistan, % of those receiving neurological emergency services reported a non-epileptic seizure or psychiatric disorder, which is much higher than the % prevalence in native germans [ ] . although mental health issues are more prevalent among refugees, mental health care for refugees resettled in the u.s. is sometimes neglected due to multiple challenges in service provision [ ] . the concept of mental health care and psychotherapy are foreign in many refugee communities [ , ] , and mental health is a stigmatized issue in refugee communities [ ] [ ] [ ] [ ] . in addition, service providers face challenges related to lack of capacity for culturally-responsive and -relevant services in many refugee-serving agencies. service providers in human and social services, as well as medical settings, often lack an understanding of refugees' cultural background and unique mental health challenges and needs [ ] [ ] [ ] . additionally, linguistic and cultural barriers keep refugees from accessing mental health services [ ] . refugee mental health interventions are the most effective when they are culturally-and linguistically-sensitive and specific to refugee groups [ ] . however, even refugee resettlement agencies, who may be equipped with better cultural and linguistic competency than most social or mental health services, struggle to recognize and respond to refugee mental health needs. despite these barriers to care, there are few training modules or opportunities that are directly relevant to refugee mental health needs. two well-known training programs available to refugee-serving professionals are training on the refugee health screener (rhs- ) [ ] and mental health first aid training (mhfa) [ ] . rhs- training is provided to refugee nurses who conduct refugee medical screening and to some refugee resettlement staff for referral purposes. although this training can help with early detection of common mental disorders (cmds), the contents are limited to basic screening and do not sufficiently prepare providers to understand and respond to refugee mental health needs. mhfa training has been delivered to refugee community leaders [ ] but has limitations in addressing mental health stigma and building hands-on competencies for service providers in the community because it was developed as psychoeducation for those with mental disorders and their caregivers [ ] . the curriculum is also not tailored to a refugee population, making it irrelevant or even culturally insensitive when it comes to meeting urgent issues of access to care and stigma. additionally, many structured training programs including mhfa are costly and dependent on the availability of culturally-competent trainers who understand refugee contexts or acculturative challenges. sustainable options are needed to ensure that mental health training is affordable and available to refugee service providers in various settings. given such gaps, the authors developed a tailored training program that helps refugee service providers build competencies related to trauma-informed care in crosscultural settings and community partnerships for referrals and coordination of care. the current study aims to identify refugee service providers' mental health training needs and to evaluate the training program in building competencies and providing tools and resources to refugee-serving professionals and refugee community leaders. in order to address the gap in culturally-competent traumainformed care in refugee resettlement services, the first author developed an interactive training curriculum based on herman's trauma recovery model [ ] and substance abuse and mental health services (samhsa)'s core principles of trauma-informed care [ ] . the training curriculum is comprised of two pillars: ( ) trauma-informed care and ( ) culture-informed care. the trauma-informed pillar is based on the idea that trauma can affect entire refugee communities, and interventions must address this trauma across all types of services and care in the community. the cultureinformed pillar is based on the idea that culture influences refugees' trauma experiences and help-seeking; thus, to provide appropriate mental health care, providers must apply or embed culturally-sensitive supports to their services. together, these pillars form the cross-cultural traumainformed approach to refugee mental health and wellness, which aims to guide stratified interventions and services for refugees and to build healing partnership among refugeeserving providers. the cross-cultural trauma-informed care (cc-tic) training was developed based on the first author's psychoeducation manual on trauma and culturally-specific, as well as general, mental health topics in the context of refugee resettlement [ ] . the training, which was delivered over two consecutive days, consists of eight . -h-long sessions, followed by a one-hour reflection and discussion session. the contents involve knowledge building (e.g., mental health terms, refugee trauma and its sequelae, refugee mental health issues, and cultural expressions of distress) and skill building (e.g., psychoeducation, listening skills, systems of care and multi-tiered intervention, community-based interventions, grounding and mindfulness, and self-care). the training contents were slightly modified for each site to meet unique as well as common needs in each locality. for example, a session on integrated care was included when many healthcare providers attended, while more contents on complex trauma were added when the community recruited providers in school settings and family services. the training was delivered by the first author at five sites in two states, over a two-year period, and was hosted by national agencies responsible for state-wide refugee health promotion programs. one site offered the training twice, once in and again in with slightly different topics. table shows the comprehensive list of training topics per locality. of note, each locality has different resettlement patterns. when providing the training, the authors aimed to focus on the major refugee ethnic and cultural groups that each site has resettled. most of the sites have many refugee groups in common, which include afghan, bhutanese, congolese and karen/karenni. after each cc-tic training, participants were asked to reflect on the training experience and assess their competencies retrospectively. retrospective study refers to data collected about interventions or programs that happened in the past [ ] . while retrospective designs may introduce bias based on participant recall [ , ] , they can allow for longer observation periods [ ] , greater generalizability [ ] , and more cost-efficient data collection [ , ] . studies have found that retrospective designs produce adequately valid and reliable results [ ] [ ] [ ] and provide information that may be less objectively true but still important [ ] . we adopted this methodology as it can allow participants to conscientiously evaluate their baseline knowledge and competencies, especially related to new subject matters, by decreasing the possibility of overestimating baseline understanding [ , ] . as such, we used retrospective study to assess participants' pre-and post-test knowledge related to refugee mental health and psychosocial support. we embedded this retrospective pre-and post-training evaluation (rppe) into a mixed-methods design. first, we had participants free list three training needs to explore gaps in capacity for refugee mental health care. then, we used rppe to assess participants' knowledge and skills in refugee mental health before community-based interventions for refugee newcomers importance and examples of community-based interventions different formats and ways to provide community-based interventions self-care and mindfulness self-care: compassion fatigue, burnout and secondary trauma grounding and mindful exercises resources resources for trauma-informed and culturally-sensitive care for refugees and after the cc-tic training. we included seven items measuring core competencies at every site (e.g., refugee trauma and mental health and trauma-informed and cultureinformed care) along with four to five additional topics that were tailored to each training site. along with the structured rppe items, we added four open-ended questions, related to the most helpful topical areas, remaining gaps, applicability of the training, and suggestions for future training. the study was exempted from irb review by the authors' institution as the training evaluation was conducted by the hosting agencies for the purpose of program evaluation and no identifiable information was obtained for the assessment. the cc-tic training aims to improve mental health competencies for not only mental health professionals (e.g., clinical psychologists/social workers and mental health nurse practitioners/counselors) but also non-mental health care providers, including refugee resettlement staff, public health nurses, school liaisons/coordinators, caseworkers, community health workers, and refugee community leaders, volunteers, and interpreters. participants self-reported their profession. they were given response options which were then grouped into three categories: ( ) mental health provider, ( ) refugee resettlement worker, and ( ) the free listing data and open-ended questions were analyzed using conventional content analysis [ ] . participants' responses were grouped into themes and categories, which were compiled to broader domains across the six training localities. for the rppe data, we ran descriptive statistics including demographic variables and frequencies of evaluation items, followed by a series of t tests, correlations and anovas to determine the average change in pre-and post-test scores according to different professions and former training experiences. all the quantitative analysis was performed in spss win ver. . the free listing data is shown in table . we identified six overarching themes in the training priorities listed by the study participants: ( ) refugee interventions and programs, ( ) refugee trauma, ( ) refugee service resources, ( ) refugee resettlement challenges and needs, ( ) provider networking, and ( ) other. of the participants, most ( . %) listed refugee interventions and programs as one of their top three training priorities. most participants ( . %) also reported learning about refugee resettlement challenges and needs as a training priority. table also shows subthemes within each of the six themes. the total and individual-item means for the evaluation data are shown in table , along with the t test results and average change in pre-and post-test score. all t tests were significant at the pre-determined cutoff point of . . for the seven core competency items included in the survey for all six localities, the average change in total core competency score was . (t[ ] = . , p < . ). the pre-test to post-test change in individual core competency score ranged from . (basic mental health terms) to . (multi-tiered model for refugee mental health and psychosocial support. table also shows four of the tailored competencies, each of which was included in at least three localities. analysis of the four open-ended survey questions revealed a set of themes. the most common theme regarding the most helpful contents (n = ) was refugee trauma and trauma-informed care (n = , . %), followed by cultural competency and cultural idioms of distress (n = , . %), and partnership building (n = , . %). others reported mental health symptoms and clinical skills (n = , . %), self-care (n = , . %), and the multi-tiered intervention model (n = , . %) as the most beneficial topics. regarding remaining gaps (n = ), most participants skipped a response or reported that all topics were clear (n = , . %). participants requested extended training on community partnership building (n = , . %), trauma recovery (n = , . %), techniques of mental health assessment and interventions (n = , . %), the multi-tiered programs (n = , . %), and self-care (n = , . %). analysis of the applicable topics and future training needs are detailed in table . table shows the results of a series of anovas comparing the average change in pre-and post-test scores by profession. these results indicated that the mean change in score was significantly different for mental health providers when compared to refugee resettlement workers and other professions for all core competency items except for refugee trauma knowledge. the aim of this study was twofold: ( ) evaluation of the effectiveness of refugee mental health training for refugee service providers and ( ) exploration of needs and challenges in building competencies for refugee mental health. first, the retrospective self-assessment shows how two-day intensive training can build competencies to help understand and respond to refugee mental health needs. though mental health professionals reported significantly higher competencies in overall topics prior to the training, the reflective post-training scores showed marginal differences across professions, and non-mental health professionals attained a good level of understanding in mental health topics and foundational skills that are crucial to trauma-informed services. it is also notable that mental health providers often do not receive professional training on trauma-related topics [ , ] , let alone specifically on refugee mental health. t in fact, mental health professionals reported the low baseline scores on refugee cmds, cultural influences on trauma and mental health outcomes, multi-tiered interventions, and trauma-informed care in this study. although most participants ( %) reported previous mental health training, there was no significant difference in preexisting knowledge of how trauma and culture intertwine to shape mental health and refugee cmds. the amount of previous experience (i.e., time) working with refugees also did not affect training outcomes in core competencies except for self-assessed general confidence prior to the training, which corroborated that work experiences alone do not build competencies in how to respond to refugee mental health needs. this implies significant gaps in currently-available training for refugeeserving professionals and a lack of culturally-responsive and -sensitive mental health training not only for those without mental health backgrounds but also for mental health professionals with formal training and direct practice experience. this study also sheds light on current needs and challenges in refugee mental health training and proposes future suggestions and strategies for building capacity for traumainformed care for refugees in various service settings. knowledge and hands-on skills for refugees with mental health needs were of the highest demand, followed by resettlement-related mental health needs and cultural knowledge to provide culturally-responsive and contextually-relevant programs. reportedly, mental health professionals showed higher competencies in overall mental health knowledge and skills and less understanding of culture-specific needs and resettlement contexts, while refugee resettlement staff and community leaders presented the opposite patterns. though mental health professionals take a critical role in community capacity for trauma-informed care and refugee mental health services [ , ] , the findings of this study also emphasize the importance of collaborative and coordinated care. participating in the training with a heterogeneous group provided insight into refugee mental health supports and situated individual programs in a broader system of care beyond segmented interventions, also helping to overcome pathologization of normal grieving processes and acculturation distress in the refugee community. participants highly valued mutual learning and networking opportunities throughout the cc-tic training, which corroborates the synergic effects suggested by previous training models to promote interprofessional learning [ ] and mutual empowerment through intercultural communication and advocacy [ , ] in community settings. this format promotes a public health approach and the principles of trauma-informed care, which underscores awareness of workshop topics that participants plan to apply to their agency or community trauma responses/trauma-informed care ( . %) "the additional knowledge was useful in that it enhanced a deeper understanding of how best to engage and accommodate families and students coping with trauma and resettlement stressors" "trauma, stress and mental health" "as a caseworker, i need to do better about addressing trauma on a daily basis" community partnerships ( . %) "i would like to see our community develop a better network of service providers" "more partnerships with community" "i am so very excited about the conversations and cross-agency community-building to come" teaching coworkers/staff ( . %) "develop workshop for coworkers, dept., & agency" "i supervise therapists-will take info back & educate them" "i would love to help provide some of this info to our clinicians in small consistent training to improve the mental health care we provide" cultural competency/population-specific information ( . %) "become more culturally sensitive; serve clients with the culture-informed lenses" "i am planning to add contents about western and non-western culture scenario into my agency's presentation curriculum" knowledge about refugee trauma experiences ( . %) "a better awareness of the background of refugee trauma" "refugee trauma and force migration" psychoeducation/community trainings ( . %) "definitely would love to do some psychoeducation and community wellness workshops with residents/clients. i also want to continue connecting with other service provider" "i also want to be able to convey that idea to community members in an approachable way that makes them better understand what refugees have gone through and continue to deal with every day" mental health knowledge ( . %) "common mental disorder in refugee population" "integrating the tiers in the process of mental treatment" community engagement ( . %) "developing trauma-informed care of my agency and be involved in community capacity" "engaging community" sharing workshop resources/exercises ( . %) "potentially considering how to expand capacity for groups and utilizing training manual for training other staff or partners" "the stone and flower exercise" self-care ( . %) "self care…preventing fatigue" "care of self" terminology ( . %) "language that i will incorporate during direct care around trauma and stress" "trauma terminology" listening skills ( . %) "i would like to more actively apply the different listening skills that were discussed" "the exercise of deep listening was very helpful. it was a good reminder that we can soften into the experience and allow the client to simply be witnessed. in a way, it's practicing humility" resettlement policies ( . %) "background on resettlement program history" "improving systems" grounding/mindfulness ( . %) "the grounding technique" "resources…to make sure we know who to go to about various concerns/needs of the refugee population" "communicating and networking to share services" "resources, community network, knowledge of providers" refugee mental health ( . %) "integrated care for refugee mental health psychosocial support" "any topic on refugee health" "anxiety, depression, trauma" trauma-informed care ( . %) "best practices for implementing trauma informed care in a resettlement agency" "trauma recovery and healing" "group work with traumatized refugees/immigrants" examples/application of learning ( . %) "i would love to have a workshop that would allow open discussions and case studies to apply the knowledge we learned from this workshop to actual practice settings" "discussing more real life/like life examples could be helpful" "video/examples of therapy session with interpreter with different techniques" community engagement ( . %) "how to encourage others to engage more with the refugee community & seek to be more involved in serving them. initiating & sustaining programs…especially fiscally" "a training on how to motivate and empower community elders and leaders to continue to practice and share their knowledge and expertise…their involvements in this area has proven to always play a significant part in strengthening community in may ways" community interventions ( . %) "community-based interventions, examples of other states" "i think a cultural competency training for specific populations with teachers and school staff would be an excellent idea and super beneficial for that communication piece" clinical skills ( . %) "trauma focus therapy for mental health providers" "communication skills" "clinical interventions for mental health practitioners who work with survivors of war trauma" cultural competency/issues for specific cultures ( . %) "further information about various cultures; a breakdown of languages, traditions, stigmas, norms, non-verbal/verbal communication, etc" "refugee population specific interventions per cultural/ethnic group (e.g., which interventions have been successful for each population)" "education about specific ethnic/cultural groups" trauma impacts not only in the refugee community but also among caregivers and service providers and emphasizes collaborative care and partnership building across service sectors to overcome challenges in mental health stigma, cultural and linguistic barriers to services, and other psychosocial issues that obstruct mental health care (e.g., transportation, insurance and eligibility, literacy, etc.) [ ] . as previous research points out [ , ] training alone may not suffice to build collaborative care across agencies and service settings. this study shows that capacity-building efforts allow an open platform to discuss common challenges across communities of practice and to reorient gaps in knowledge and skills on an individual level to advocacy and partnership at organizational-and community-levels. regardless of localities, participants were enthusiastic about the idea of providers' networks or partnership meetings to regularly discuss refugee mental health issues despite such challenges as lacking buy-in or internal supports from leadership, few resources for community-wide action, and limited interagency accountability. as a naturalistic evaluation study, this research has some limitations to consider. the study was conducted as part of program evaluation by two state-wide refugee health programs and turned into a case study of five resettlement sites with no comparison groups. follow-up to track how participants retain and utilize training competencies would be beneficial and is the next step of this study. retrospective measures were efficient in this study due to limited selfawareness on unknown topics (e.g., cultural humility); however, future research may consider adopting a conventional pre-and post-test design to assure improvement in competencies over time. also, an in-depth study on how partnerships can be built across mental health fields and psychosocial programs would help design an effective community partnership or coalition model addressing common refugee mental health challenges beyond services working in silo. this study contributes to the field by addressing gaps in knowledge related to mental health training and capacity building in the context of refugee resettlement services. we developed and implemented training on refugee mental health that is culturally sensitive and contextually relevant to service environments, which fills gaps in the field related to lack of appropriate trainings for refugeeserving staff. we have also proposed an innovative training approach that emphasizes mutual learning and partnership building opportunities. the culturally-responsive traumainformed approach helps bridge gaps between mental health care and psychosocial services in current refugee lgbtq refugees & how they can be supported" "incorporating undocumented survivors experience" more in-depth coverage ( . %) "an advanced training on this topic" "future workshops could build further on the knowledge that [the facilitator] shared. she had to skip over a lot of material just due to the time constraints involved" "more in depth discussion of cultural expressions of trauma; bodies' response to trauma ( . %) "how trauma affects physical health" "psychosomatic pain" refugee trauma experiences ( . %) "resettlement stories" "refugee trauma pre and migration" trauma recovery ( . %) "anything that would help refugees overcome their trauma is welcome" "trauma recovery and healing" self-care ( . %) "self-care" "staff trauma and stress management" integrated care ( . %) "integrated care for refugee mental health psychosocial support" grounding/mindfulness ( . %) "i would have enjoyed more physical/relaxation/grounding exercises or movement or interactive exercises" potential triggers ( . %) "potential triggers of body language asking questions etc" resettlement program, which can promote exchanges of knowledge and expertise to build collaborative care and community partnership. table items and mean scores by profession, across sites *p < . **p < . ***p < . a participants self-reported their profession with response options which were then grouped into three categories: ( ) mental health provider, ( ) refugee resettlement worker, and ( ) other (collapsed from the remaining options: healthcare provider, social services, interpretation, medical liaison/community health worker/medical case manager, teacher/provider in school setting, university researcher, refugee program supervisor, refugee community leader/volunteer, community-based organization, or other) psychological distress and adjustment of vietnamese refugees in the united states: association with pre-and postmigration factors the impact of interpersonal and noninterpersonal trauma on psychological symptoms in refugees: the moderating role of gender and trauma type dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among cambodian survivors of mass violence psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among west nile refugees association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies neurological emergencies in refugees access to mental health treatment by english language proficiency and race/ethnicity knowledge of depression and depression related stigma in immigrants from former yugoslavia this doctor, i not trust him, i'm not safe': the perceptions of mental health and services by unaccompanied refugee adolescents beyond stigma: barriers to discussing mental health in refugee populations barriers to health care access among refugee asylum seekers exploring the "fit" between people and providers: refugee health needs and health care services in mt roskill barriers to care: the challenges for canadian refugees and their health care providers new directions in refugee youth mental health services: overcoming barriers to engagement review of refugee mental health interventions following resettlement: best practices and recommendations the refugee health screener- (rhs- ): development and validation of an instrument for anxiety, depression, and ptsd in refugees mental health first aid: an international programme for early intervention mental health first aid training for the bhutanese refugee community in the united states trauma and recovery: the aftermath of violence-from domestic abuse to political terror substance abuse and mental health services administration: samhsa's concept of trauma and guidance for a trauma-informed approach rockville trauma-informed cross-cultural psychoeducation (ticcp): mental health training for refugee community leaders & mental health care providers (interactive training manual). richmond, va: virginia commonwealth university and virginia department of behavioral health and developmental services synthesis of literature relative to the retrospective pretest design: in: the joint ces/aea conference bias in retrospective studies of trends in asthma incidence social work research methods: from conceptualization to dissemination retrospective studies: a fresh look looking back from death: the value of retrospective studies of end-of-life care panel : methodological issues in conducting pharmacoeconomic evaluations-retrospective and claims database studies psychopathology and early experience: a reappraisal of retrospective reports validity and reliability of a method for retrospective evaluation of chlorophenate exposure in the lumber industry a retrospective survey of childhood adhd symptomatology among adult narcoleptics a retrospective survey of childhood experiences retrospective preevaluation-postevaluation in health design three approaches to qualitative content analysis responses of a sample of practicing psychologists to questions about clinical work with trauma and interest in specialized training the need for inclusion of psychological trauma in the professional curriculum: a call to action promoting mental health and preventing mental disorder among refugees in western countries screening for war trauma, torture, and mental health symptoms among newly arrived refugees: a national survey of us refugee health coordinators interprofessional student meetings in municipal health servicemutual learning towards a community of practice in patient care promoting hmong refugees' well-being through mutual learning: valuing knowledge, culture, and experience cross-cultural training in mental health care-challenges and experiences from sweden and germany bridging community intervention and mental health services research approaching the vulnerability of refugees: evaluation of cross-cultural psychiatric training of staff in mental health care and refugee reception in sweden building capacity to care for refugees acknowledgements we wish to thank all the community partners who supported and organized the refugee mental health training and the program evaluation. this study would not be possible without all the participants who joined the training and shared their valuable opinions and suggestions. key: cord- -axv kys authors: van beveren, laura; rutten, kris; hensing, gunnel; spyridoula, ntani; schønning, viktor; axelsson, malin; bockting, claudi; buysse, ann; de neve, ine; desmet, mattias; dewaele, alexis; giovazolias, theodoros; hannon, dewi; kafetsios, konstantinos; meganck, reitske; Øverland, simon; triliva, sofia; vandamme, joke title: a critical perspective on mental health news in six european countries: how are “mental health/illness” and “mental health literacy” rhetorically constructed? date: - - journal: qual health res doi: . / sha: doc_id: cord_uid: axv kys in this study, we aim to contribute to the field of critical health communication research by examining how notions of mental health and illness are discursively constructed in newspapers and magazines in six european countries and how these constructions relate to specific understandings of mental health literacy. using the method of cluster-agon analysis, we identified four terminological clusters in our data, in which mental health/illness is conceptualized as “dangerous,” “a matter of lifestyle,” “a unique story and experience,” and “socially situated.” we furthermore found that we cannot unambiguously assume that biopsychiatric discourses or discourses aimed at empathy and understanding are either exclusively stigmatizing or exclusively empowering and normalizing. we consequently call for a critical conception of mental health literacy arguing that all mental health news socializes its audience in specific understandings of and attitudes toward mental health (knowledge) and that discourses on mental health/illness can work differently in varying contexts. media coverage on mental illness and its effect on public beliefs and attitudes toward mental health problems have long been and still are a topic of scholarly interest (cabrera et al., ; mcginty et al., ) . previous research has shown that mainstream media often negatively associate mental illness with danger, violence, and sensation, which might contribute to social and self-stigma and hinder people experiencing mental distress from seeking (professional) help (corrigan et al., (corrigan et al., , savage et al., ) . mental health literacy initiatives and awareness campaigns aimed at educating the public about mental illness, its causes, and available treatments options are considered valuable tools in the reduction of stigma and in the encouragement of more appropriate help-seeking behavior (jorm, ; kelly et al., ; wahlbeck, ) . central to many of these literacy projects is the "mental illness as a disease like any other" approach. this approach aims to replace beliefs, myths, and moralistic understandings of the nature, cause, and treatment of mental illnesses with bioneurological scientific facts, which are considered to improve public attitudes toward mental illness by reducing perceived individual responsibility and blame (gardner, ; read et al., ) . the emphasis on such medical literacy has been related to linear understandings of news media as means to transmit takenfor-granted scientific information to a lay audience (hallin & briggs, ; seale, ) . critical health communication researchers have critiqued this approach: rather than focusing on the scientific and medical accuracy of health news coverage, these scholars emphasize the constructed nature of health news and have indicated the need for more research that recognizes and studies the different ways in which media are actively involved in the social construction of what constitutes health and illness (dutta, ; lupton, ; zoller & kline, ) . in this study, we aim to contribute to the field of critical health communication research by examining how notions of mental health, mental illness, and mental health literacy are discursively constructed in the mental health reporting of newspapers and magazines in six european countries. in the following sections, we first align ourselves with critical-discursive theories of mental health/illness. next, we connect these perspectives to the field of critical health communication by drawing on briggs and hallin's ( ) recently developed framework of biocommunicability. this framework conceptualizes the different ways in which media constructions of (mental) health and (mental) illness operate in the governing of the healthy citizen as they implicitly communicate to the audience ideas on what constitutes legitimate (mental) health knowledge and who produces, circulates, and consumes it. following the arguments of briggs and hallin ( ) , this study is thus not concerned with demonstrating the value of mental health news in enhancing the scientific and medical literacy of the readers, but rather aims to study how all news stories communicate specific ideas on mental health/illness and on how different actors should engage with mental health (knowledge). scholars and advocates from various disciplinary fields have emphasized the epistemologically and ontologically ambiguous nature of mental illness and have contested the uncritical adoption of psychiatry, clinical practice, and their classifications of mental health and illness as scientific-objective, neutral, and acultural (bracken & thomas, ; kleinman, ; pickersgill, ) . drawing on conceptions of human (inter)subjectivity as embedded in social, historical, and cultural contexts, these authors instead disclose mental health/illness as a value-laden notion that is grounded in specific cultural constructions of the relationship between mind, body, and society (teo, ) . building on the works of foucault, rose ( rose ( , ) has studied the cultural impact of psychiatric discourse on our understandings of (mental) illness and health. he illustrates how neoliberal and biopsychiatric subjectivities currently intersect in discourses that center around the enterprising self, which have increasingly come to occupy domains of life such as leisure, education, and media. in this process of biomedicalization, the enterprising self appears as a rational subject that manages social risks, which now appear as the individual genomic risk (to develop a mental disorder) that everyone carries, by constant self-monitoring and by making well-informed health and lifestyle decisions (see also clarke et al., ; dumit, ) . the framework of biocommunicability, recently developed by briggs and hallin ( ) , is especially concerned with the performative and pedagogical power of health news in the production of cultural understandings of health, disease, biomedicine, and the healthy citizen more generally. the framework aims to elaborate on the concept of biomedicalization by relating it to the process of biomediatization, referring to media's "co-production of medical objects and subjects through complex entanglements between epistemologies, technologies, biologies, and political economies" (p. ). in line with criticalinterpretive perspectives on health communication (on this, see dutta, ; lupton, ; zoller & kline, ) , briggs and hallin ( ) consider public health and medicine on the hand, and communication and media on the other as impinging upon and co-producing one another, rather than as two separate spheres, with the role of the latter reduced to representing to an audience that needs to be informed about the preexisting medical objects and subjects of the former (seale, ) . indeed, the fact that psy-discourses are no longer confined to traditional professional and institutional psy-domains and have instead come to occupy mainstream and popular media channels (binkley, ; kirkman, ) requires an understanding of mental health news as actively negotiating cultural legitimacy for specific conceptions of mental health/illness (knowledge) (kurchina-tyson, ) . according to briggs and hallin ( ) , the performative or biopedagogical power of health news manifests itself in the two layers that can be distinguished in each health news story: in addition to providing the audience with cultural understandings of health and disease, they teach the public about what counts as valuable health knowledge, who produces it, how it circulates, and who receives it. health news is thus performative and pedagogical in the sense that it interpellates different actors to take different positions toward health knowledge and socializes the audience in specific ideas of what counts as biocommunicable success (accepting ascribed positions) or biocommunicable failure (failing to take up or challenging ascribed positions). although the framework of biocommunicability focuses on health and disease in general, kate holland ( , a , b has engaged with it to study how media and communication figure in the biopolitics of mental health/illness in particular. the framework of biocommunicability distinguishes three cultural, normative models of production, circulation, and reception of (mental) health knowledge, each of them "woven into the words and images of stories themselves" (briggs & hallin, , p. ) . the model of biomedical authority assumes media communication on health to follow a linear-hierarchical trajectory in which biomedical authorities produce health knowledge that is subsequently communicated to a not-yet-knowing and passive lay audience. distinctions between knowledge and nonknowledge about health are constructed in terms of good science (i.e., objective facts, technological progress) versus bad science (i.e., pseudo-science, myths, and beliefs) (briggs & hallin, ) . in this context, health news often appears as a form of health education given its commitment to enhance the public's medical and scientific literacy (hallin & briggs, ) . with regard to mental health, this model can be related to the "mental illness as an illness like any other" approach to mental health literacy (read et al., ) . the patient-consumer model, which according to briggs and hallin ( ) has overruled the dominance of the former model, assumes a more agentic role for the service user/patient and shifts biocommunicable power relations to introduce a concept of the public as consisting of rational and active information seeking individuals that are capable of making choices and managing their own health/treatment (briggs & hallin, ) . this resonates with rose's ( ) notion of the enterprising self, with (mental) health appearing as a commodity that should be actively and responsibly pursued by everyone. in this context, (mental) health journalism takes up the role of informing the public about all of the treatment choices available, often drawing on the genre of first person celebrity-accounts or stories about persons overcoming their (risk of developing) mental health problems (binkley, ; briggs & hallin, ; holland, ) . again, (mental) health news acts as a form of health education, with mental health literacy appearing as a matter of access to information to make the right health decisions, and as an asset that might actually "do much of the work" and reduce either the need for or the unnecessary use of (costly) public services (teghtsoonian, , p. ) . the public sphere model disrupts the traditional biocommunicable hierarchies evident in the two previous models by considering health, medicine, and science as value-laden, contingent, and contestable notions that can and should be debated publicly. service users/patients and the public at large are addressed as citizens who have both stakes in public health discussions and valuable contributions to make. by being an (implicit) ally to the public or taking up an activist stance themselves, journalists support a process of renegotiating what counts as legitimate or expert knowledge about health (briggs & hallin, ) . with specific regard to mental health/illness, much of the activist and theoretical work in this area has been done by advocates, researchers, and professionals involved in the critical disability and survivor movements, whose efforts have called attention to the complex interplay of the material, historical, cultural, and political constituents of mental health problems (goodley et al., ; lefrançois et al., ) . in an important note on the three models, briggs and hallin ( ) remark that the discursive workings of a health news story often cannot be confined to one particular model, but rather form biocommunicable cartographies in which different models combine and intersect in complex, sometimes contradictory ways. the complexity of mental health/illness news thus calls for an analysis that goes beyond binary classifications of media representations as either positive or negative. in the next section, we explain how we set up a qualitative study using rhetorical analysis as a methodological lens to examine the cultural understandings of mental health/illness and the biocommunicable cartographies produced and circulated in mental health news in six european countries. this study is part of the larger "mentally-together for better mental health care" research project. the project has received funding from the european parliament and aims to gather qualitative information on mental health professionals' and service users/patients' perspectives and the public mental health debate to gain a better understanding of notions of access and quality in european mental health services. in the project, researchers from six european countries, that is, cyprus, greece, belgium, the netherlands, sweden, and norway, collaborate to form an interdisciplinary research team that covers the disciplines of clinical and social psychology, public health studies, and discursive-rhetorical studies. the selection of the six countries was informed by their scores on the euro health consumer index which includes countries measured on indicators. the six countries reflect an adequate amount of european diversity considering patient rights and information, accessibility of health care, health outcomes, range and reach of services provided, prevention efforts, and use of pharmaceuticals. furthermore, the selection of three pairs of countries allows for a diversity in economic-political and cultural contexts (e.g., with the economic situation of greece and cyprus largely characterized by the consequences of the "crisis years" and severe austerity measures), yet also assures the inclusion of countries with comparable cultural contexts, but different mental health service systems (e.g., the norwegian system being much more centralized than the swedish system). the project was ethically approved by the ghent university ethical commission on march , (for more information, see http:// mentally-project.eu/). data were collected through a systematic key word search in mainstream media sources in all six european countries. more specifically, in each country, the two most read quality newspapers and popular newspapers were searched as well as the most read senior's, men's, women's, lifestyle, sports, popular scientific, tv, opinion/ news, and teen magazine. it has been argued that various new media, such as social media, blogs, and websites, have become important sites of information exchange, social support, and even mental health service itself (giles & newbold, ; lal & adair, ; moorhead et al., ) . nevertheless, newspapers can still be considered mainstream in the sense that they remain influential in the construction and dispersion of public understandings of mental health (chadwick, ) , or, as briggs and hallin ( ) stipulate, in "setting the terms of public debate" (p. ). our search was limited to the online content of the sources with the aim of developing an online database to store the collected data. as we collected both freely accessible articles and articles that were behind a paywall, we had access to largely the same content of the paper versions of the sources. moreover, given the fact that in , more than nine out of households in the netherlands, sweden and norway, more than eight out of households in belgium and cyprus, and more than three out of four households in greece had internet access (eurostat, ), we believe that online information (especially of mainstream media sources) represents not an exhaustive, but a representative sample of all information content in the particular countries. given the various ways to name mental health (problems), we used a broad range of key terms that were scanned for in all text, including "mental health," "mental wellbeing," "mental illness," "mental disorder," "psychiatric problems," "psychological issues," as well as the names of specific mental health issues, such as "depression," "burn-out," "schizophrenia," and "bipolar disorder." data collection covered a period of weeks between september and october resulting in a data set of articles. table presents an overview of the collected data for each of the six european countries. all of the newspaper and magazine articles that mentioned one of the key terms were included in the study and were descriptively coded using the following tags: title, date, language, and abstract (one-sentence summary) of the article, "who speaks" in the article (e.g., academic scholar, celebrity, professional), target group (e.g., adolescents, women), mental health issue (e.g., depression, burn-out), newspaper section (e.g., science, lifestyle, opinion piece), and key terms evident in the article. based on the reading and descriptive coding of the articles, each country identified the five main topics in their public mental health debates. an overview of these topics is provided in table . we selected a smaller subset of data for the interpretive analysis of the cultural understandings of mental health/ illness and the biocommunicable cartographies produced and circulated in the newspaper and magazine articles. each country selected five representative articles for each of their five main topics. to include less dominant perspectives, all countries also selected an additional five articles that did not belong to any of the five main categories. this resulted in a data set of articles. our interpretive analysis specifically builds on the field of rhetoric as a methodological framework. in line with discursive studies of "mental health/illness," a rhetorical analysis attempts to account for the complexity in how people make sense of "mental health/illness" and associated service use (sims-schouten & riley, ). rhetorical studies of mental health communication, however, are particularly concerned with how certain understandings of mental health/illness become persuasive and thus productive in the constitution of the healthy subject, and how and why they appeal to specific audiences that are either already there, assumed, or created (dumit, ) . in this study, we conducted a rhetorical cluster-agon analysis to (a) first identify larger patterns in the media sources' cultural construction of mental health/illness and (b) then gain deeper insight into the rhetorical strategies that are used to persuade people of both these understandings and their concomitant biocommunicable positions. the first stage of the analysis thus takes a more inductive approach and examines what understandings of mental health/illness mainstream media currently rely on, while the second stage more deductively draws on the framework of biocommunicability to explain how these understandings of mental health/illness are rhetorically constructed and how they persuade the audience of specific ideas on who produces, circulates, and consumes valuable and legitimate mental health knowledge (cf. mental health literacy) (on the importance of using qualitative methods to understand both the what and the how of health communication, see foley et al., ) . the analytical method of cluster-agon analysis is primarily based on the assumption that when we communicate, our terminology comes together in associational clusters (burke, ) . the analysis then, is aimed at identifying "what goes with what" (positive terms, such as synonyms, characteristics, comparisons) and "what goes against what" (negative or agon terms, such as negations, terms in competition, or at odds with each other) in these clusters and how these linguistic patterns (re)produce certain understandings of reality (foss, ) . a cluster-agon analysis consists of three steps. first, the key terms of the rhetorical action have to be determined, which in our case corresponded with the search terms each article was tagged with during the descriptive analysis (e.g., mental illness, mental wellbeing, depression, and so on). next, the researcher examines the contexts in which the key terms occur and identifies the terms that positively and negatively cluster national and international trends related to mental health issues around the key term in these contexts. to interpret what terms are most meaningfully associated with the key terms, the principles of frequency, location, and emphasis can be applied. in a third and final step, the text is interpreted by discerning wider discursive patterns in the associations or oppositions discovered in the clusters (for a more extensive explanation, see foss, ) . to deal with the issue of analyzing materials in different languages, each researcher analyzed the articles of their geographical area individually for the first two steps of the rhetorical cluster-agon analysis and then reported on the results in english by providing an overview of each article's key terms, positive clusters terms, and agon cluster terms using a shared template. the third step of the analysis was performed by the researchers with expertise in the domain of rhetorical and discursive studies and was reported back to the research team to make sure the findings of the study aligned with the rest of the team's interpretations of the data. we identified four dominant terminological clusters in the newspaper and magazines' mental health reporting, with mental health/illness conceptualized in terms of (a) danger and risk, (b) a lifestyle issue, (c) a unique story and experience, and (d) social trends and factors. below, we describe how each of these understandings is rhetorically constructed by discursively associating and disassociating specific groups of cluster terms. we also elaborate on how each of the clusters communicates specific ideas on what counts as valuable mental health knowledge (cf. mental health literacy) by relating them to the three models of biocommunicability. in each of the six countries' public mental health debates, we identified a cluster that approaches mental health problems in terms of danger, risk, and violence. this cluster is most apparent in news articles that relate mental health problems to (pseudo-)criminal activities, with the terminology used to refer to people with mental health problems ranging from judicial language (e.g., the accused, the offender) to biomedical language (e.g., psychiatric patient) and language that relates to madness (e.g., a disturbed person, a sick mind). interestingly, these terminologies do not appear as the agon of one another, but instead paradoxically intersect. for example, in one article, a woman who struggles with mental health problems is referred to as both a "notorious troublemaker"/"attacker" and a "vulnerable psychiatric patient"/"sweet lady." especially in the case of serious crimes that seem to have no clear motive, such as a parent murdering a child or a very young perpetrator committing a violent crime, news reports ambiguously draw on terminology that refers to both determinism and agency. statements such as "there was no intention or motive," "i wasn't myself," or "i couldn't control my impulses," suggest a passive role for the individual involved and instead consider mental illness to be both the explanation and the agent of the action. still, individual responsibility is implied as is illustrated in terms such as "remorse," "apologize," or "mental illness is used as an excuse." a more explicit reference to the assumption of agency can be found in judges' or journalists' indication that the person who committed a crime did not seek psychological help in time or did not take their medication on a regular basis (table ) . the association of mental health issues with danger, risk, and threat is a trope that, as holland ( a) notes, is not specifically accounted for in the model of briggs and hallin ( ) which focuses on the issue of health news more generally. however, our data suggest that news coverage that relates mental health problems to crime is still largely informed by the biocommunicable model of biomedical authority, with most of the terminology surrounding the concept of mental distress referring to biomedical psychiatry (i.e., illness, disorder, diagnosis, treatment, medication, and psychiatric expert). interestingly, within this cluster, the biomedical authority model might work as both a destigmatizating force by taking away part of the blame and responsibility for the crimes committed, and as a stigmatizing force by reinforcing conceptions of mental illness as medical dysfunctions that cannot be remedied. the language reflecting the agency of the person with mental health problems illustrates that the patient-consumer model operates in this cluster as well. by associating crime and punishment with reluctance to turn to professional help in time or to take one's medication in a responsible way, news stories on crimes committed by people with mental illnesses can function as examples of biocommunicable failure to manage one's mental health. another group of articles that reinforces both the biomedical authority and the patient-consumer model by relating mental health problems to danger and risk, consists of news reports that disseminate recent research findings on what increases or decreases the possibility of developing mental health problems. central to the terminology of these articles is the concept of "risk," that functions to present mental illness as an ever-present threat to "healthy individuals" and "healthy societies." in line with the biocommunicable model of biomedical authority, journalists generally take on the role of passing on scientific expert knowledge on what constitutes a "risk profile" or who belongs to a "risk group" to a not-yet-knowing audience. specific demographic groups, in our data mostly adolescents, the elderly and (pregnant) women, are singled out as "especially vulnerable" and thus especially responsible to manage their risk of developing mental difficulties. only very rarely, journalists comment on the fact that there is no consensus on the validity of certain research findings yet among scholars and (mental health) professionals. our cluster analysis furthermore shows that scientific terminology often intersects with neurological and technological terminology to create the equation that more technology equals more individual, neurological, statistical data which, in its turn, is assumed to lead to less risk of mental health problems and thus healthy individuals and healthy societies (table ). in several news articles, economic interests are integrated in the formula as well, with the costs of persons who experience mental health problems (in terms of economic, social and human capital) presented as posing an economic threat to healthy societies. although the first cluster mainly focuses on "mental illness" or "mental health problems," this cluster emphasizes the importance of actively pursuing "mental wellbeing," "quality of life," and even "happiness" (table ). in the public mental health debates, the first and second cluster often do not operate as each other's agons. rather, they intersect in prevention logics that take the individual as their primary object of intervention and that are heavily embedded in the patient-consumer model of biocommunicability and its notion of the enterprising self. within this cluster, news articles encourage the general public to actively manage their mental health, with the key to a healthy mental life to be found in a healthy lifestyle, which includes healthy eating habits, healthy sleeping patterns, physical exercise, and a responsible use of technology and social media. the strong presence of lifestyleterminology (way of life, life attitudes) in conjunction with self-terminology (self-improvement, self-care, self-regulation) suggests that taking care of one's mental condition is not only primarily a responsibility of the individual, but also a lifelong commitment. within this cluster, mental health literacy appears as a prominent aspect of mental health care and is conceived of as a pedagogical project with news and magazine articles "informing" and "educating" the audience with "tips," "tricks," and "advice" on how to maintain a healthy lifestyle. although this lifestyle journalism has a clear relation to the patient-consumer model, we identified examples of biomedical authority within this cluster as well. in several of the articles, the association of mental health and lifestyle is underpinned by biomedical scientific and professional expert knowledge, often invoking neurological explanations referring to the brain and hormones. nevertheless, this cluster complements traditional authoritative knowledge on mental health/illness with new sources of information, including expert advice from life coaches, labor experts, and health insurance companies, advertisements from pharmaceutical companies, and insights from people who personally experienced mental health issues. we identified examples of people sharing experiences of dealing with mental health problems with a larger public in all of the six countries' media sources. in some of the countries, these so-called "first person accounts" even dominated public discussions of mental health/illness. the term "story" and other narrative terminology seems of particular importance to people's description of their (or a friend's or relative's) experiences of dealing with mental health problems and of processes of stereotyping and stigmatization (e.g., "everyone has their own story," "see the story behind people," or "don't judge a book by its cover"), which emphasizes the subjective and personal dimension of experiencing mental health problems. indeed, the testimonials often do not conceptualize mental health problems from a single perspective, as is reflected in the biopsychosocial terminology in this cluster (cf. terminology referring to the bodily, psychological, emotional, and social dimensions of mental health problems). likewise, a variety of potential sources of support are mentioned, including professional help from a family doctor, therapist or psychiatrist, psycho-pharmaceuticals, alternative therapies, and nonprofessional help such as support from friends, family or fellow-sufferers/survivors, and self-care. a closer examination of the testimonials reveals that several stories are built around a linear "made it"-narrative: after people's journey to find the help most suited for them, they reach a point of "peacefulness" or "stability" and "finally feel like themselves self again." such "redemptive story turning points" have been considered important in the process of regaining personal agency (kerr et al., ) . however, one of the messages conveyed to the audience in such stories seems to be that everyone can find out "what works for them," which resonates with conceptions of biocommunicable success within the patient-consumer model. indeed, in one of the news articles, a scholar critiques the "conditional openness" of media toward stories that fit certain "feel good"-narratives. occasionally, we found the third cluster to intersect with the first and second one in articles that report on people's successful attempts to prevent mental health issues (see titles such as "i almost suffered from a burn-out"; table ). understandings of mental health issues in terms of personal stories or experiences also adhere to the more emancipatory dimension of the patient-consumer model as they validate the experience of service users/survivors as a legitimate source of knowledge on "what works best." various testimonies question the dominance of the biomedical psychiatric perspective as the only or most authoritative form of knowledge on mental health problems. they display ambiguous attitudes toward the use of pharmaceuticals, mention negative experiences with professional help or share stories about the beneficial effects of alternative therapies and nonprofessional help. some of these more critical testimonies explicitly speak from a public sphere model of biocommunicability and address their critiques directly to the mental health care system and the politicians, policy makers and professionals behind it (on this, see also cluster ). in most cases, however, the "experience" (or "proximity" in the case of relatives or friends) of people dealing with mental health issues works as a form of "knowledge" or "expertise" to convince people with similar experiences that change is possible and that there is no shame in asking for (professional) help. "knowledge by experience" is ascribed both an informative and a supportive role, as is evident from expressions such as "our insights are like medicine" or "hearing and sharing stories can be therapeutic." in addition, it is engaged with as a means to break persisting stereotypes and taboos surrounding mental health problems and to create a climate in which mental health issues can be talked about more openly. a major rhetorical strategy deployed in the testimonies' antistigmatization work, is the establishment of a process of identification with the readers, emphasizing throughout the stories that people with mental health issues are actually "just like you," that "we are all humans" and that "everybody struggles." interestingly, on some occasions, attempts to identify with the larger public coincide with the creation of new divisions. especially in the case of mental problems such as depression, anxiety, and burn-out, people sometimes emphasize the importance of opening up about mental struggles, yet cluster terms that focus on the individual individual behavior, you, personal, self-care, self-regulation, selfimprovement, self-awareness, self-esteem cluster terms that focus on orientations to act " signs that . . . ," warning signs, " tips to . . . " tricks, advice, advertisement, improve, succeed, reach outcomes and goals, make choices, recognize, prevent, manage, coach, protect, counteract cluster terms that focus on pedagogy educate, train, psycho-education, education, parents, increase your knowledge intersection with economic cluster terms economic interests, profitable, productivity, work, labor expert, efficient, consumers, market, invest, social/human capital, expensive, societal costs, medical costs, destruction of resources intersection with neurological cluster terms brain, neurotransmitters, neuroscientist, hormones, dopamine shots, serotonine, melatonine, brain activity, exercise your brain, a quick and sharp brain, brain development note. adhd = attention-deficit/hyperactivity disorder. simultaneously reassure the audience that they are "not crazy." the language of "craziness" or "madness" is also apparent in some of the more sensationalist media reports "revealing" the mental health problems of celebrities, turning their "confessions" into objects of curiosity and entertainment for the audience (see, for example, clickbait titles such as "doctor, i am crazy and i am dying: greek singer shocks!"). although in the three previous clusters, the individual is most prominently featured as the object of attention, the fourth cluster focuses on the social dimension of mental health/illness (table ) . since this cluster does not have a specific thematic focus, we will elaborate on three topics that frequently recurred, each of them characterized by a specific set of associated cluster terms. the first topic concerns critiques on the organization of the mental health care system, in most cases formulated by (mental health) professionals or service users/ survivors. the problems most frequently targeted in the critiques include the inaccessibility of mental health services, waiting lists getting longer due to a lack of care accommodation, and the system's overreliance on medication as a quick fix for complex psychological problems. politicians, policy makers, pharmaceutical companies, and medical professionals are explicitly addressed as the audience of the critiques, with calls to increase the government's mental health care budget, to develop carecentered instead of administration-centered policies, and to educate professionals on the value of various therapies. the terminology in this cluster pinpoints attention to a question that is often left out in the previous clusters, namely, whether we can guarantee that a person that wants to be helped professionally will be able to find and access appropriate care. this not only raises the question whether our mental health care system allows people to take on the role of the active and empowered patientconsumer, but, on a more fundamental level, challenges the notion as such. for example, in cases where people who need professional help distrust the system (e.g., due to psychotic episodes), putting the responsibility to ask for and find professional help mainly with the individual in mental distress (and their close environment) might hamper their chance of getting the appropriate care. the second topic that draws on social terminology in its discussion of mental health, concerns the identification of societal trends that might impact the wellbeing of the general population. high pressure workplace environments as well as technological developments, social media, and the concomitant expectation of always being available are singled out as leading to "a tsunami" of stress, burn-out, anxiety, and depression. although some articles complement their analysis with calls on employers to develop wellbeing policies or with a more radical rejection of our "performance society" altogether, others turn their attention to the individual again, asking "what we can do to live a life that is free of technostress?" or arguing that "changing our reactions to culture can be liberating." here again, appeals are being made to the "enterprising individual" that, once informed about the social risks threatening its wellbeing, will be able to make the right health choices (see also cluster ). finally, a small number of articles discusses how social inequalities and power differentials in our societies affect the mental wellbeing and mental health care of marginalized groups. furthermore, some articles critique how in current political and ideological debates people who struggle with mental health issues are portrayed as threatening out-groups (together with, for example, people who suffer from drug addiction or prostitutes) as a way to rationalize their exclusion from a society that is not capable of-or not willing to-provide basic needs for the most vulnerable members of its population. the terminology used in these articles differs from the terms traditionally dominating public discussions of mental health/illness. for example, instead of "stigma," concepts such as "discrimination," "violation of rights," and "social exclusion" are used to describe experiences of repression, criminalization or exclusion in society and the mental health care system. orientations to act shift from "hearing and sharing stories as therapy" to "activism," "advocacy," and "political awareness as therapy" with specific attention being paid to the material realities in which people are expected to take care of their mental wellbeing. these articles contained the most outspoken references to a public sphere model of biocommunicability with the unusual targeting cluster terms "mental health care system" mental health system, mental health services, mental health care, waiting lists, no accessibility, no availability, lack of care accommodation, not enough treatment capacity, unacceptable, illegal use of force and isolation cells, medication as quick fix, over prescription and overuse of medication, pharmaceutical companies, selling illness, bureaucracy, market forces in care system, constant monitoring, administration, hold politicians accountable, government fails, participation society fails, policy, financing, budget, resources alternative help circuit (e.g., care farm), person centered care, care time, care centered policy cluster terms "societal trends" technology, social media, facebook, whatsapp, work mail, technostress, information society, labor market, stress, high pressure, high expectations, performance society, neoliberal society, productivity, tsunami of burn-outs, burning boomers, generation z, psychological problems or our time cluster terms "societal power differentials" "experts in discrimination", discrimination, inclusion, diversity policy, violation of rights, democracy, social exclusion, repressive policies, intersectionality, power, politics, marginalized population, equal citizens, government advocacy organizations, voice, activism, organized actions, political awareness as therapy power imbalance and tackling societal issues, unequal society, socioeconomic living conditions, health insurance, financial poverty, neoliberal conservatism, capitalism, productivity, disposable people "experts in therapy," lack of training in "stigmatized identities" chemical imbalance and treating symptoms psychological problems of politicians, policy makers, and mental health professionals as the objects of pedagogical or literacy interventions in which they need to learn from "experts in discrimination." interestingly, in some articles the term "psychological problems" appeared as an agon term, reminding the audience that not all problems can be reduced to individual mental distress and that in some cases "tackling societal issues and power imbalances" rather than "treating symptoms or chemical imbalances" might be the more appropriate way to act. in this study, we examined media coverage on the topic of mental health problems and mental wellbeing in a broad range of newspapers and magazines from six different european countries. we specifically analyzed how the discursive association and disassociation of cluster terms (cf. "what goes with and against what") creates specific understandings of what constitutes the mentally healthy or ill subject. drawing on the framework of biocommunicability, we furthermore sought to examine how each of the clusters relates to the concept of mental health literacy and persuades its audience to take up particular attitudes toward mental health (knowledge). our findings illustrate that public discussions of mental health/illness inevitably draw on terminological clusters, with the clusters of "mental illness as dangerous," "mental wellbeing as a matter of lifestyle," "experiencing mental health problems as a unique story," and "mental illness as socially situated" being the most dominant in our data. while some news and magazine articles clearly aligned with one of the four clusters, we identified many examples where different clusters and biocommunicable models intersected to create complex, sometimes paradoxical, terminological and biocommunicable cartographies. these findings suggest that particular discourses can function differently in public mental health debates and that they cannot be unambiguously judged as either exclusively problematic and stigmatizing or exclusively good and empowering. we argue that the method of rhetorical analysis might respond to the methodological challenge to capture the nonlinear and complex effects of specific discourses on public understandings of and attitudes toward mental health/illness (briggs & hallin, ) , since the rhetorical and productive power of psy-discourses precisely lies in the fact it might accommodate multiple interests (thornton, ) . in our analysis, we indeed identified several examples of the complex and multiple workings of specific discourses (or terminological clusters) in relation to topics such as stigma, empowerment and mental health literacy. for example, discourses of dangerousness and risk, sometimes in coalition with discourses of sensation, were clearly present in our data. this is in line with previous research findings (nairn, ; sieff, ) and was perceived as negative and conforming stereotypes of people with mental difficulties being out of control in many of the first person accounts. although mainstream media thus contribute to the persistence of negative stereotypes, they also take an active role in counteracting them with the taboo-breaking first person accounts appearing as one of the most dominant types of mental health reporting in several of the six countries. the biomedical "mental illness as a disease like any other" approach was often engaged as a tactic to normalize mental illness and taking psycho-pharmaceuticals in particular in these narratives. however, research has shown that increased medical literacy does not necessarily result in increased social acceptance of people with mental illness (schomerus et al., ) and might even strengthen ideas of dangerousness and unpredictability (read et al., ) . our analysis of the crime reports provides an apt illustration of this double rhetorical effect of stigmatization and destigmatization of biopsychiatric and medical discourse. in many of these articles, concepts such as "diagnosis" and "illness" functioned to take away blame, yet also coincided with punitive, law and order, and criminalizing terminology as they strengthened deterministic beliefs that "this person will not change" and "there is too high a risk of relapse." inviting empathy and understanding is considered to be another effective rhetorical strategy of anti-stigmatization and normalization in mental illness narratives (lewiecki-wilson, ) . in our study as well, establishing identification with the audience was central to many of the first person accounts' efforts to normalize the experiences of people with mental health problems. in a few cases, however, people's identification attempts coincided with a reassurance of the audience that they were "not crazy," implying a hierarchy between more and less socially acceptable mental health problems. although our data did not contain explicit references to mental problems considered to belong to the last category, most of the personal narratives and lifestyle advice focused on burnout, depression, suicidal thoughts, anxiety, and mental health problems in general, with bipolar disorder, psychosis, and schizophrenia less frequently or not at all openly discussed. similarly, a study of newspaper coverage on mental illness in the united kingdom indicates that in the past decades coverage for depression has become less stigmatizing, but has remained largely negative for schizophrenia (goulden et al., ) . this could possibly be explained by mainstream media's tendency to sanitize mental health news and focus on upbeat and safe narratives that largely fit biomedical authority and patient-consumer conceptions of biocommunicable success (holland, a) , rather than on stories about schizophrenia and psychosis that have long been associated to "classical madness" (wahl, , p. ). one a more fundamental note, rothfelder and thornton ( ) question whether empathy and understanding are unambiguously desirable rhetorical effects at all. they remark that the growing acceptance and popularization of the term obsessive compulsive disorder (ocd) (cf. expressions such "i am so ocd as well") might have some unproductive effects, such as too simplistic and unquestioned understandings of what ocd is and what it means to live with it. rather than focusing our communication exclusively on empathy and acceptance, we should be more sensitive toward the critical potential of "rhetorical acts that do not seek uncomplicated acceptance or understanding from their audiences" as tools of antistigmatization and resistance (rothfelder & thornton, , p. ) and should look into the diversity of reasons people have for choosing whether or not to disclose their mental health issues (bril-barniv et al., ) . in the same way discourses play various roles in the rhetoric of (de)stigmatization, they can perform differently in the rhetoric of empowerment as well. the findings of our study largely confirm briggs and hallin's ( ) argument that, in the context of (mental) health, current understandings of empowerment are largely embedded in patient-consumer models of biocommunicability, which emphasize client/consumer-centered practice and individual decision-making as leading principles of (mental) health care. similar to the case of biopsychiatric discourse, juhila et al. ( ) argue that empowerment-discourse gains its power from its potential to underpin varying projects of change in current welfare states and services. in our data, logics of agency (e.g., notions of "expertise by experience" in personal narratives) intersected with logics of consumerism (e.g., media presenting a healthy lifestyle as a commodity to be purchased by their readers) and individualization (e.g., translating social problems to problems of individuals being at risk), to create understandings of empowerment that simultaneously affirm the audience's autonomy to make choices and their responsibility to make the right choices. these discourses of responsibilization often prioritize the notion of mental health literacy over mental health service and focus attention to the information and knowledge gaps of individuals or the general public rather than the social and materials contexts in which individuals are expected to monitor their mental health (esposito & perez, ; teghtsoonian, ) . we did encounter some resistance toward these discourses within the fourth cluster, which tried to change the scope of analysis and intervention from the individual to the collective and societal level as well as within some of the personal narratives which addressed shortcomings in mental health practice and policy, rather than in the general public's mental health literacy. although patient-consumer models heavily impacted understandings of empowerment and mental health literacy in our data, there was a clear presence of the biomedical authority model as well, especially in the form of neuro-discourses. we did not elaborate on the bio-neurological perspective as a separate cluster since it nearly always appeared in conjunction with the three first clusters. dumit ( ) notes that neurological conceptions of mental illness have become so persuasive that the brain has almost become a synecdoche for one's identity. when combined with the autonomy as responsibility-logic, this leaves people with the difficult choice between the "toosimple cultural alternatives of either being responsible for your sickness or not being your brain" (dumit, , p. ) . our data did indeed contain some evidence of people trying to negotiate understandings of their neurological (rose, ) or pharmaceutical (dumit, ) selves, balancing between understandings of their mental health problems as "a part of them" versus as "a brain dysfunction that needs to be fixed with medication so i can be myself again." this again reminds us that we cannot simply judge specific discourses as either stigmatizing or empowering and that we need to understand the choices of people with mental health problems to self-identify in certain ways within larger sociocultural understandings of what constitutes good and healthy citizens. this article has aimed to contribute to the field of critical (mental) health communication studies by examining how newspapers and magazines actively mediate public understandings of mental health/illness and simultaneously communicate ideas on who should produce, circulate, and receive mental health knowledge. our analysis of the performative effects of the terminological clusters that underpin public discussions of mental health/illness revealed that we cannot take for granted the straightforward destigmatizing or empowering effects of biopsychatric discourses or discourses aimed at empathy and understanding. we consequently argue that, rather than searching for the ultimate correct and destigmatizing mental health/illness knowledge and discourse, health communication research should examine how discourses work differently in varying contexts and how they might be productive in both the formulation of positive selfidentifications and in the creation of new lines of division and exclusion. in addition, such a "discursive awareness" might be relevant for clinical practice as well, since professionals might become "mindful of the effects of their use of language and make the contingent nature of their knowledge explicit" (lofgren et al., , p. ) . one of the limitations of this study is its restriction to a -week period of news coverage, which means that specific topics might have been overrepresented or missing in our data. however, as our aim was not to track down changes over time in media coverage of mental health/illness, we contend that our data set was comprehensive and diverse enough to allow us to gain insight into larger terminological patterns and complexities in current mental health/illness reporting. in line with lynch and zoller ( ) , we furthermore contend that methodological perspectives from the field of rhetorical studies might offer valuable contributions to the field of health communication, especially because of its potential to study how language constructs specific cultural understanding of health, illness and literacy and how, at particular moments, these constructions become persuasive to particular audiences and particular causes. we confined our analysis to the empirical study of written, online mental health news. however, future studies might fruitfully draw on the framework of biocommunicability and the method of rhetorical analysis to study how cultural understandings of mental health (literacy) are constructed in a variety of other empirical contexts, such as service users' activist and advocacy work, policy documents, or professional discourse. since research has shown that dynamics of media coverage and stigmatization might be different for specific mental health issues, future research might also study the rhetorical effects of specific discourses for specific mental health problems, such as depression, burn-out, or schizophrenia. in addition, although this did not fall within the scope of this study, future research might apply comparative methodologies to gain insight into the potential impact of political, economic and cultural contexts on media coverage of and main themes about mental health within countries. finally, we suggest that mental health awareness campaigns and mental health literacy policy initiatives broaden their scope from focusing on the need of the general public to educate themselves on one form of mental health knowledge to the need for everyone, including journalists, policy makers, professionals, service users, and researchers, to develop a critical mental health literacy, which includes a critical meta-awareness of the ways in which we are all confronted with various cultural constructions of mental health/illness, and "recruited to take our assigned roles in producing, circulating, and receiving health knowledge" (briggs & hallin, , p. iv) . ine de neve works as a research assistent at the department of experimental clinical and health psychology. her research focuses on the perspectives of clinical professionals on the current and prospective belgian mental health care. mattias desmet works as professor and lecturer of psychoanalytic psychotherapy at the department of psychoanalysis and clinical consulting at ghent university. his research focuses on the process and outcome of psychoanalytic psychotherapy. alexis dewaele is professor and coordinator of psync, a consortium within the field of clinical psychology, at ghent university. his research interests include sexual health and identity, social networks, stressors in minority groups and mental wellbeing. theodoros giovazolias is associate professor of counselling psychology at the department of psychology at the university of crete. his research interests include family issues, parent counselling and bullying and victimization. dewi hannon works as a research assistant at the department of experimental clinical and health psychology at ghent university. her research focuses on therapeutic change in the treatment of medically unexplained symptoms. organizational psychology at the psychology department, university of crete and director of the applied psychology laboratory. he is also affiliated to the aristotle university of thessaloniki. his research interests include emotion in interpersonal and social interaction, in hierarchical relationships at work, and in social relationships across cultures. reitske meganck is professor and lecturer of clinical psychology at the department of psychoanalysis and clinical consulting at ghent university. her research interests include the process and outcome of psychoanalytic psychotherapy using mixed method designs in group and single case research. simon overland is adjunct professor at the university of bergen and leads a team of researchers analysing burden of disease and risk factors at the norwegian institute of public health. his research interests include population health, mental wellbeing epidemiology and general public health. sofia triliva is associate professor of clinical psychology at the department of psychology at the university of crete. her research interests include identity formation 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psychiatrica scandinavica health and media: an overview media frames of mental illnesses: the potential impact of negative frames presenting critical realist discourse analysis as a tool for making sense of service users' accounts of their mental health problems depression and mental health in neoliberal times: a critical analysis of policy and discourse critical psychology: a geography of intellectual engagement and resistance race, risk, and pathology in psychiatric culture: disease awareness campaigns as governmental rhetoric. critical studies in media communication media madness: public images of mental illness public mental health: the time is ripe for translation of evidence into practice theoretical contributions of interpretive and critical research in health communication konstantinos kafetsios is also affiliated with aristotle university of thessaloniki, thessaloniki, greece. the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the european parliament (grant pp- - , topic: pp- - - ) and the ghent university special research fund (doctoral scholarship bof- -doc- ). laura van beveren https://orcid.org/ - - - dewi hannon https://orcid.org/ - - - notes . we recognize that, according to theoretical or political position, terminological preferences to refer to "mental health (issues)" and "service users" can differ. in this article, we will use varying terminology mainly trying to remain as closely as possible to the specific terms used in the public debates and the literature we study. . definitions of "most read" differ according to the information available in each country, for example, highest number of (online) subscribers or highest number of sold copies. laura van beveren works as a doctoral researcher at the department of educational studies at ghent university. her research interests include rhetorical analysis and critical reflection in clinical psychology. key: cord- -npt i bc authors: poole, norman a. title: if not now, when? date: - - journal: bjpsych bulletin doi: . /bjb. . sha: doc_id: cord_uid: npt i bc the editor of the bjpsych bulletin reflects on the extraordinary recent events triggered by the covid- pandemic. mental health professionals are at the front line of managing the pandemic and emergency changes should lead to a much needed refocus on what is really vital. in these unsettling times we ought to review how we manage the crisis, and its aftermath, both personally and professionally. my -year-old daughter woke this morning with a cough. rather sweetly, she claimed she'd 'caught hold of the cough' which she knows is making people ill. instead of the group cycle i'd planned, i rode out on my bike alone, giving others an acceptably wide berth. well, i say acceptably wide, but how wide is that? two metres or more? should i even have been out exercising? is it a cold or covid? how worried should i be? pedalling into a cold northerly squall, it suddenly dawned on me: 'i'm scared'. not so much for myselfalthough perhaps i'm not yet willing to admit thatbut for my daughter, my family, friends, their families, colleagues and, of course, our patients. we are taught that insight in psychosis is impaired, but i've often found anxiety to be less well recognised by patients, and me it turns out, than the textbooks tell us. it was an unsettling discovery because at that moment i also realised how powerless i am. the neuropsychiatry team at st george's where i work had spent the previous week switching to remote clinics, mainly from home, but also seeing neurology in-patients at st george's hospital. we learned that the liaison psychiatry service, led by the unflappable marcus hughes, had split into red and green teams; the former working exclusively in the new covid- unit. 'how noble?', i thought. 'how long will they last?', i fretted. everyone accepts that at some point they will have to take their turn in the red team. we heard how our in-patient colleagues on the mental health wards are also dividing themselves into teams and containing units to mitigate the virus's spread. 'how ironic?', i mused. doctors were first sent to the asylums some years ago to prevent contagion seeping out into the community at large. now we are struggling to do the opposite. community teams are restructuring services on the hoof to maintain care despite all the limitations imposed on them. as i write, it still feels like a phoney war, yet so unnerving to watch our futures unfolding before us in daily despatches from the frontlines in italy and spain. in this war against an invisible enemy the frontline is long, and thin. and mental health professionals are as much part of it as anyone. i personally hate churchill's quip about 'not letting a good crisis go to waste', which so blithely ignores human cost and personal tragedies. yet i am surely not alone in believing that covid- must change how we deliver mental healthcare for good. the pandemic, from which we will hopefully recover, and our catastrophic mismanagement of the environment are not unrelated events. pathogens are increasingly likely to cross species barriers as we pillage natural habitats. tomlin's editorial draws attention to healthcare's contribution to poisonous greenhouse emissions and a previous article in this journal described the damage that excreted ssri medications could be wreaking on our marine environment. we are currently working towards a special edition of the bjpsych bulletin on the climate crisis and psychiatry, which will highlight the problems and point to some solutions. in this vein, i am hopeful that many of the new ways we are workingtelepsychiatry and stripped-back bureaucracywill outlive the current crisis. psychiatry must resist successive governments' fantasy that individual risk can be managed on the basis of population-level statistics. , it can't, and we must say so. the reality is, we would probably have the workforce to deliver a world-class mental health service if everyone wasn't so tied up inputting pointless data. if not now, when? the virus has also exposed glaring injustices in our society. some have the resources to weather the storm either through accumulated wealth or the luxury of being able to work from home. many others live hand-to-mouth in insecure jobs while paying extraordinary housing costs. how will they fare? the sacrifices being made across the board must lead to a rewriting of the social contract, as happened after the second world war. the debts currently being accrued cannot be repaid with regressive income taxes while personal and corporate wealth remains undertaxed. unlike post- , corporate bailouts must come with conditions that benefit the majority. later this year, with peter byrne's support, bjpsych bulletin will publish a themed edition on inequality as a major source of mental disorder. i'd say it is timely, but we have known this stuff for years yet not always, it seems, accepted the corollary: psychiatry must argue unflinchingly for a fairer society. if not now, when? this crisis will be demanding on us all, but social distancing also provides opportunities. as i cycled alone, which i expect to be doing a lot more of, i realised just how addicted i'd become to the relentless news cycle. i've resolved to limit my intake to once a day. much better to repurpose these new uninvited evenings spent at home. sadly, i doubt it'll be to learn the piano but in these strange times i'm opening up to music recommended by others (please send some suggestions!) and have been live streaming gigs from my favourite venue (café oto, if you're interested: https://www.cafeoto.co. uk). there are various writing projects that i aim to complete before unwinding with movie nights. i have already had an evening in a virtual pub and reconnected with longlost friends. all the while knowing that these are mere displacement activities to manage a gnawing fear. it will be harder still for the completely self-isolating over- s. many i know are self-organising to support the vulnerable locally, and it will be a testament to our society if these activities endure. closer to home, i've started a book club with my mum to help keep her spirits up in the long months ahead and allow us to chat about something, anything, else. and there are plenty of books that have sat on my to-do list far too long. my apocalyptic reading starts here: if not now, when? insight and psychosis: awareness of illness in schizophrenia and related disorders a history of psychiatry: from the era of the asylum to the age of prozac global rise in human infectious disease outbreaks the climate crisis and forensic mental health care: what are we doing? prescribing' psychotropic medication to our rivers and estuaries pokorny's complaint: the insoluble problem of the overwhelming number of false positives generated by suicide risk assessment the hcr- and violence risk assessment: will a peak of inflated expectations turn to a trough of disillusionment? use it or lose it: efficiency gains from wealth taxation (nber working paper ) crashed: how a decade of financial crises changed the world if not now, when? penguin modern classics none. key: cord- - nyzwb authors: das, nileswar; narnoli, shubham; kaur, apinderjit; sarkar, siddharth title: pandemic, panic, and psychiatrists - what should be done before, during, and after covid- ? date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: nyzwb nan since the world health organization (who) has declared coronavirus disease as a pandemic in january- , more than -countries have been affected with over million confirmed cases. although the part to be played by psychiatrists to pacify global panic in peri-pandemic period is not defined anywhere, psychiatrists should take a leadership role, both in crisis intervention, and long term mental health mentoring (tandon, ) . this is a time of uncertaintiesall individuals are uncertain about their health and economic outcomes. also, there is overwhelming misinformation, stigma, prolonged isolation, and disruption of daily routines. all these factors can impact one's psychological-wellbeing j o u r n a l p r e -p r o o f (brooks et al., ) . fear and anxiety had led to suicides, communal disharmony, and crimes against essential service providers (sharma et al., ) . not only individuals with confirmed or suspected covid- but several other vulnerable groups (e.g. health care workers, persons with mental illness etc.), despite remaining uninfected, will continue to suffer from psychological infirmity. therefore, we need an intervention plan to address mental-health problems during the pandemic (das, ) .  psychological preparednessto what is coming. it can help individuals to take stock of their coping and prepare them to deal effectively with stressful situations.  early detectionof psychiatric manifestations and distinguishing normal reactions to stresses from mental disorders.  psychiatric interventionto take care of psychological trauma following the pandemic. psychosocial/psychiatric rehabilitationcommunity reintegration.  performing researchesto generate an evidence base for formulating further course of action and policy-making. what are the possible roles to be played by psychiatrists during various phases of the pandemic?  public awarenessproviding the right health information is vital during this time of crisis -(i) to address hand hygiene and safe physical distancing, (ii) to reduce panic j o u r n a l p r e -p r o o f shopping and hoarding of medical equipment (e.g. masks, hand-sanitizer, antibiotics), (iii) to follow the national lockdown to avoid widespread community transmission, (iv) to maintain adequate mental and physical wellbeing and (v) misinformation restriction to avoid chaotic and stressed environments in the country (bhatia, ) , (sharma et al., ) . one possible solution could be reaching the common public through local leaders and influential celebrities using the same media.  homeless, immigrant and migrant crisisproviding shelter and food can mitigate the problem to some extent. but the huge psychological stress and possible future adversities remain to be addressed. providing adequate psychological support from others, including family members, by being in contact on the phone, along with the resources provided by the government, may be crucial to saving many lives.  medical preparednesslockdown is a relative measure to buy time for medical preparedness. establishing designated hospitals, provision of personal protective equipment and life-saving drugs are crucial but providing psychological support and trauma preparedness training to the emergency care providers can reduce their anxieties and significantly reduce the future psychological trauma in these work-groups (lai et al., ) .  resource allocation -during the pandemic, one of the important things that needs to be done is testing of suspected individuals, contact tracing and isolation of suspected cases. allocation of both man-power and fund to this needed activity would be necessary. mental health care providers here may also need to take up the role of a primary health care provider when needed and as per their training statutes.  psychological wellbeing of vulnerable groups -most vulnerable groups needs to be taken care of. we need to step-up in providing telepsychiatry consultation to the individuals who may not physically follow up for various reasons.  continued psychiatric follow up services -it is important to provide continued services to the previously registered mentally-ill patients to refill or adjust their medication without any need to visit hospital. this is particularly important both because lockdowns have made it difficult to travel, and continued social distancing practice can enforce hospitals to restrict number of non-emergency patient visits in coming future .  shutdowns, lockdowns, and forced quarantines -it is very likely to have prolonged lockdowns during pandemic progression. ensuring the supply of daily needs is one aspect, while at the same time, the real challenge would be maintaining one's psychological wellbeing. digital media can be used as a source to train individuals and promote the ways of (i) upholding a healthy lifestyle, (ii) maintaining a near-normal daily routine, (iii) relaxing exercises to deal with stress and, (iv) other ways of coping.  social distancing vs physical distancing -'social' distancing appears to be a misnomer in the present time. in this tough time, maintaining social contact with friends and families is very crucial while maintaining safe physical distancing (galea et al., ) . psychiatrists can promote social bonding through the use of telecommunications to minimize the loneliness in these already scary times. can lead to fear and anxiety, and may also lead to stigma. it is also important to 'avoid labelling' the affected individuals or community as 'victims'. it would be necessary to support emergency service providers and to stop spreading rumours. one should seek adequate help if someone is annoyed being identified with illness or being marginalized in society. studies have shown stigma to be directly associated with poor mental health outcomes in the long run (kane et al., ) .  disaster management -in the aftermath of covid- , the situation would be more similar to a natural disaster. with a high number of individuals being under stress, many may show signs of anxiety, depression, posttraumatic stress disorder, among many other psychological disturbances. economic difficulties consequent to the pandemic may also lead to an increase in rates of mental health problems, substance use disorders, and suicides. integration of mental health care with already existing public health services to provide basic psychological support may help to combat long term psychological adversities in the societies. the role of mental health care providers divided above into various phases of the pandemic may not follow the strict pattern and may overlap in reality. they also have to play usual role addressing the mental health of those admitted in in-patient, emergency or intensive care units (acute psychosis, acute mania, catatonia, suicide and delirium); role in breaking badnews and also the mental health providers themselves to keep their calm (avoid getting overwhelmed by the rise in mental morbidity). in summary, covid- is anything but only an infectious disease. various far-reaching psycho-socio-economic adversities will have serious mental health issues. psychiatrists and other mental health professionals need to step up, utilizing 'all-out' resources to prevent a post-covid- mental-illness pandemic. the authors do not have any conflicts of interest to report financial disclosure the present study was non-funded. the authors do not have financial disclosures public engagement is key for containing covid- pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence psychiatrist in post-covid- era -are we prepared? the mental health consequences of covid- and physical distancing: the need for prevention and early intervention a scoping review of health-related stigma outcomes for highburden diseases in low-and middle-income countries factors associated with mental health outcomes among health care workers exposed to progression of mental health services during the covid- outbreak in china a chaotic and stressed environment for -ncov suspected, infected and other people in india: fear of mass destruction and causality the covid- pandemic, personal reflections on editorial responsibility none j o u r n a l p r e -p r o o f key: cord- -qhyjhk r authors: wissow, lawrence s.; platt, rheanna; sarvet, barry title: policy recommendations to promote integrated mental health care for children and youth date: - - journal: acad pediatr doi: . /j.acap. . . sha: doc_id: cord_uid: qhyjhk r nan public health and health care systems face many challenges as indicators of acuity and demand for child mental health services increase. , , these systems have not been designed to detect problems early and intervene with potentially preventive interventions. , in addition, the child mental health workforce lacks sufficient capacity as it is presently configured. integration of mental health services into primary care has been promoted as one answer to these challenges, and is endorsed by national and international organizations. , nearly all children have primary care visits, and the philosophy of pediatric primary care in the us is oriented toward universal prevention, surveillance, and early intervention. primary care providers are seen as credible sources of psychosocial information and guidance, and many families express a preference for getting psychosocial care in a primary care rather than a mental health setting. some of this preference comes from primary care being a more familiar and potentially less stigmatizing place to receive mental health care, a factor that may be especially salient to patients who already experience racial or ethnic stigma. incorporating mental health as part of "routine" medical care also sends a message that emotional well-being is an essential part of one's overall wellness. prior to the beginning of this century, very few pediatricians worked in close coordination with mental health professionals. despite evidence that child/youth integrated care can be effective and practical, , still only about half of us pediatricians consider that they work in practices co-located with a behavioral health professional. integration continues to face significant barriers, including lack of consensus on how primary care and co-located mental health professionals should share roles, the need for substantial transformation in how practices operate if they are to provide mental health care, financing schemes that do not incentivize treatment in primary care or collaboration with mental health providers, and a lack of mental health practitioners trained to work in primary care settings (especially in linguistically and culturally diverse communities). , to these structural barriers, however, additional dilemmas have emerged as the field of integrated care has evolved. first, there is the realization that conceptualizing integrated care as a binary partnership between mental health and primary care does not address the high level of co-occurrence of mental health, developmental, and psychosocial problems that limit the effectiveness of mental health treatments when they are applied in isolation. as the us and much of the world enter into an era of unprecedented social and economic challenge related to the novel coronavirus, which has disproportionately impacted populations already experiencing limited access to mental health services, the need to expand the scope of integration will only become greater. second, there is the difficulty of translating the most widely known models of integrated care, developed in adult medicine, into pediatrics. compared to adult integrated care, child mental health integration must contend with presentations that vary significantly with age, which complicates screening and other forms of case-finding. child mental health treatment relies more on brief, practical psychosocial interventions compared to easier-to-deliver medication titration. , in addition, while nearly everyone's mental health is related to that of the people they live with, children's mental health outcomes are particularly dependent on their parents' own mental health, and thus treatment often must include plans to address parents' treatment needs and parent-child interactions. the american academy of pediatrics has issued a policy statement outlining what it sees as pediatric providers' responsibilities to address parental mental health, but there remains little precedent for directly addressing parent mental health in pediatric primary care, despite its profound effects on children. to date, integrated care has benefited from attempts at federal, state, and professional society levels to promote its implementation. with some exceptions, however, such as the centers for medicare and medicaid services' inck initiative, and efforts by the american board of pediatrics and the american academy of pediatrics, , , there has been a greater emphasis on doing so with care for adults. . other policy analyses have addressed how health systems as a wholeincluding those with integrated care components, can promote child and family well-being in general. the following recommendations focus more narrowly on integrating mental health into pediatric primary care. the recommendations are intended as a guide to policymakers, health system leaders and educators, and research funders; they address four goals that, based on the analysis above, we believe are central to the growth and effectiveness of pediatric integrated care: first and foremost, policies must promote changes in the scope of pediatric primary care so that it can comprehensively address families' psychosocial needs. multi-generational social and emotional wellness needs to be accepted as an integral part of pediatric care and these aspects of health need to be effectively assessed and treated by pediatricians and/or in collaboration with community-based services that address social determinants of health. , state and federal programs have the ability to influence these transformations through regulatory changes, financial incentives, and corresponding technical assistance. individual providers and health care organizations need the clear guidance, motivation and knowledge of how to go about modifying their practices and building the community alliances they will need to provide truly integrated care. requiring health care systems to report mental health-related metrics will allow state and federal authorities to optimally leverage incentives. specific initiatives could include: a. federal and/or state incentives for implementing "advanced medical home" or "high performing medical home" , models that are foundations for integrated care. states can support these models by giving practices additional payments if they meet criteria for certification (see financing recommendations below). incentives could be tailored to reward the use of integrated care to address disparities in mental health services and outcomes, as well as to reward coordination of child/youth and adult mental health services. b. the federal government could expand past policy statements regarding the detection and treatment of parental mental health problems as part of pediatric primary care. expansions could include that attention to parental mental health extends beyond concern for maternal depression in the perinatal period, as well as stating the appropriateness of including relevant parent mental health information in the child's medical record. these statements, coupled with increased training for pediatricians in the detection and initial assessment of parental health issues, could help to clearly include attention to parental mental health as within the scope of pediatric practice. d. hrsa could expand and institutionalize its support so that all states could have so-called "child psychiatry access programs" that promote interprofessional collaboration and education supporting mental health service delivery in the pediatric primary care. , these programs provide informal mental health consultation to primary care providers around specific patient's problems, and many currently have primary care provider training and practice transformation components which could be expanded to include helping integrated behavioral health providers (including those in schools) adopt and use evidencebased brief interventions or telepsychiatry when necessary. coordinated with these "access programs," states, health care organizations, and philanthropy could fund additional mental health skills training for primary care providers, taking advantage of the "access programs" ability to provide long-term, ongoing consultation and support for practice c. states can expand the use of billing codes that support collaborative work so that both primary care and psychiatric providers can be paid for indirect consultation, case review, and coordination of referrals for both children and parents. as part of paying for collaborative care, states can also allow billing for the services of community health workers or navigators who can link families to needed follow-up services and reinforce/deliver mental health treatments (see below in workforce). d. the federal government and private insurers could allow wider latitude for billing for parent-directed services that also have potential for impact on the child. third, policies need to encourage development of the workforce so that integrated care can be delivered at scale. not only is there a general lack of child mental health workforce in most areas of the country, there is an even greater lack of providers trained to work at the interface of medicine, mental health, and community supports. , , in our increasingly diverse society, this workforce has to speak multiple languages and be capable of delivering care to families from multiple cultures. a. the federal government, states, and philanthropy could subsidize mental health training for peer/community health workers/navigators who would ideally be recruited from diverse communities and whose services could be paid for through medicaid prevention or case management mechanisms. , subsidies to payers or health care providers could be tied to increasing the linguistic and cultural diversity of the workforce and providing long-term career pathways for those who start out in these important but entry-level positions. , b. states could finance additional residency/fellowship slots in pediatrics, family practice, and child psychiatry that focus on integrated care. c. states could require exposure to integrated care skills and meaningful training in mental health for any existing slots that the state currently funds, especially those aimed at producing physicians who will go into primary care. states would have more leverage if medical education accreditation and licensing bodies required robust mental health curricular components in training programs for all primary care disciplines including mds, dos, physicians assistants and nurse practitioners. d. states could additionally finance slots or tracks in nursing (including advanced practice), social work, and psychology, programs that target work in co-located or community settings. , finally, research dollars are needed to develop the case-finding methods and interventions that will bring pediatric integrated care to its full potential. this includes further development of screening processes that promote actionable discussions with families about their psychosocial strengths and weaknesses, trans-diagnostic and trans-system (medical and social) approaches to treatment, , more potent and deployable psychotherapeutic interventions suitable for primary care (including those that specifically address parent-child interaction), a. development and testing of brief, broadband (trans-diagnostic) therapies that can be readily learned by individuals with and without formal mental health training and that can be delivered to families in a variable number of short sessions. , b. adaptation of parent support and parent-child interaction interventions for primary care, both in early childhood and across the pediatric age range. , c. investigation of alternative models of well-child care (such as group visits) that recognize the priority within well-child care for supporting the mental health and psychosocial needs of families. , d. exploration of novel uses of ehealth for providing integrated care services, including expanded use of telemedicine, the use of follow-up text messages and other modalities to prolong the impact of brief in-person mental health interventions, and the integration of on-line treatments for parents and other caregivers into services based in pediatrics. , e. development of efficient training and ongoing support programs for community health workers, peer navigators, and others who can both extend the mental health workforce and increase its capacity for providing care in diverse languages and from diverse cultural perspectives. , f. studying processes related to practice transformation and interaction across systems, with particular focus on ) methods for including diverse families in the design and adaptation process of interventions, and ) efficient methods for providing initial and long-term assistance to practices and systems as they implement and refine integrated care. integrated care is considered to be one of the most promising directions for addressing inadequacies in the delivery of child and youth mental health services. it offers the opportunity to build problem detection and early intervention into an existing system of child health monitoring and promotion, as well as to create a greatly expanded number of sites where child and youth mental health care can be delivered. however, growth of pediatric integrated care continues to face barriers built into the way that pediatric primary care is delivered and financed. policies need to support transformations in the scope of pediatric primary care, as well as financing mechanisms that make these transformations sustainable. a larger and more diverse mental health workforce will be needed to support an expansion of pediatric integrated care. training programs for both primary care providers and a variety of current and potential mental health providers must provide clinicians with the skills they need to engage and help families in the primary care setting. finally, there remains much to be learned about interventions that could make pediatric integrated care more potent and easier to implement. fortunately, there are strong foundations on which to address all of these needs; it should be possible to coordinate efforts in these directions and move pediatric integrated care forward at a time when it is particularly needed. time trends in symptoms of mental illness in children and adolescents in canada trends in psychiatric emergency department visits among youth and young adults in the us years in the united states primary health care: potential home for familyfocused preventive interventions preventing the incidence of new cases of mental disorders: a meta-analytic review leveraging collaborative care to improve access to mental health care on a global scale committee on psychosocial aspects of child and family health, mental health leadership work group. mental health competencies for pediatric practice caring for children and adolescents with mental disorders: setting who directions. geneva, world health organization summary health statistics for u.s. children: 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pediatricians aap agenda for children: medical home plan/pages/aap-agenda-for-children-strategic-plan-medical-home.aspx maternal depression screening and treatment: a critical role for medicaid in the care of mothers and children. department of health and human services integrating mental and physical health services using a socio-emotional trauma lens massachusetts child psychiatry access project . : a case study in child psychiatry access program redesign a national examination of child psychiatric telephone consultation programs' impact on children's mental health care utilization effectiveness of the extension for community health outcomes model as applied to primary care for autism: a partial stepped-wedge randomized clinical trial massachusetts food is medicine state plan overcoming barriers to rural children's mental health: an interconnected systems public health model psychometric properties of the emotion dysregulation inventory in a nationally representative sample of youth pragmatic health assessment in early childhood: the promis® of developmentally based measurement for pediatric psychology regional health edecisions: a guide to connecting health information exchange in primary care. ahrq publication no. - -ef behavioral health services following implementation of screening in massachusetts medicaid children challenge guide: payment reform to address social determinants of health in children fostering social and emotional health through pediatric primary care: a blueprint for leveraging medicaid and chip to finance change behavioral health integration in pediatric primary care: considerations and opportunities for policymakers, planners, and providers integrated pediatric behavioral health: implications for training and intervention models community health workers for patients with medical and behavioral health needs -challenges and opportunities mental illness and well-being: an affect regulation perspective improving parenting skills for families of young children in pediatric settings: a randomized clinical trial prime: a programme to reduce the treatment gap for mental disorders in five low-and middle-income countries a single-session growth mindset intervention for adolescent anxiety and depression: -month outcomes of a randomized trial enhancing parent talk, reading, and play in primary care: sustained impacts of the video interaction project well-child care clinical practice redesign for serving low-income children a telehealth-enhanced referral process in pediatric primary care: a cluster randomized trial a computer-assisted depression intervention in primary care lay counselor perspectives of providing a child-focused mental health intervention for children: task-shifting in the education and health sectors in kenya. front psychiatry ensuring quality in psychological support (who equip): developing a competent global workforce transforming physician practices to patientcentered medical homes: lessons from the national demonstration project co-designing an intervention to prevent overweight and obesity among young children and their families in a disadvantaged municipality: methodological barriers and potentials change in patient outcomes after augmenting a low-level implementation strategy in community practices that are slow to adopt a collaborative chronic care model: a cluster randomized implementation trial the authors are grateful to drs. marian earls, jane foy, j. david hawkins, and robert hilt for suggestions as we compiled this set of policy goals and recommendations. key: cord- - nhbzybq authors: liu, jianghong; potter, teddie; zahner, susan title: policy brief on climate change and mental health/well-being date: - - journal: nurs outlook doi: . /j.outlook. . . sha: doc_id: cord_uid: nhbzybq climate change has a significant global impact on individuals’ mental health and well-being. however, global health systems are inadequately prepared to address this issue. studies indicate that climate events such as floods, droughts, tornados, earthquakes, and fires not only exacerbate chronic mental illness, but also impact well-being causing anxiety, stress, and in the worst case, suicide. the world health organization estimates that . million preventable deaths per year can be attributed to environmental factors, all of which are exacerbated by climate change, and an additional , deaths per year are projected between and . nurses must advocate for research, education, and policies that support disaster-resilient infrastructure and human services that allow communities across the globe to effectively mitigate the impact of climate change on human health. climate change is a fundamental threat to public and mental health and is already affecting individuals and communities across the globe. the world health organization estimates that . million preventable deaths per year can be attributed to environmental factors, which are exacerbated by climate change (world health organization, ). an additional , deaths per year are projected between and (world health organization, . furthermore, in the wake of the covid- pandemic, climate change, land use, and biodiversity loss are all connected and can contribute to the spread of future pandemics and diseases (vidal, ) , with % of the world's infectious diseases coming from the natural environment (brennan & micklas, ) . while the negative impact of climate change on physical health is acknowledged, recent evidence also points to profound adverse effects of climate change on well-being and on the exacerbation of existing acute and chronic mental health conditions. climate change related weather extremities and natural disasters impact mental health and well-being by disrupting health care resources and access, the economy, and social structures, and endangering the natural and social environments upon which people depend for their livelihoods, health, and well-being (o'neill et al., ; watts et al., ) . the nature of these changes disproportionately leaves impoverished and marginalized populations particularly vulnerable to the psychological stress and economic costs of climate-related disasters, causing already-disadvantaged groups to suffer disproportionately. while research continues to emerge, current evidence suggests that a wide range of serious physical and mental health consequences, including post-traumatic stress disorder (ptsd) and suicide and/or suicidal thoughts, result from exposure to climate-related disasters clayton, manning, krygsman, & speiser, ) . ptsd may stem from serious injury, death of family members, or forced displacement from home and is common as a result of natural disasters. the effects of climate change on ptsd has been primarily documented in the context of waterrelated disasters across countries and ethnicities. for example, after the torrential downpours and unstable levy infrastructure of hurricane katrina in , the psychological aftermath continued to persist in its survivors; within just a few months after katrina, the prevalence of ptsd in louisiana and mississippi rose from % a few months after katrina to % only a year later (kessler et al., ) . nearly % of adults (mclaughlin et al., ) and % of children (lai, kelley, harrison, thompson, & self-brown, ) had posttraumatic stress at some point afterwards. more recently, a study documented that at least twothirds of houston respondents indicated some level of post-traumatic stress from hurricane harvey in , which induced flooding of at least centimeters in more than , homes (grineski, flores, collins, & chakraborty, ) . the effect of flood-related disasters on ptsd has also been observed globally. one study investigating the effects of a severe flood in spain in found that the likelihood to suffer ptsd was . times higher in the population affected by the flood, with symptoms lasting for several months following the traumatic event (fontalba-navas et al., ) . another study conducted in india was consistent with reports in the united states and spain, with flood exposure substantially associated with ptsd and moderated by disrupted social support systems including family separation and broken peer connections (dar, iqbal, prakash, & paul, ) . given the enduring and far-reaching effects of ptsd symptoms following extreme rain and flooding, the development of population-scale methods and resources to combat ptsd is critical. similar to ptsd, rates of suicide and suicide ideation increase during times of climate-change related events, with heatwaves and droughts being especially concerning. alarmingly, a recent study has reported that rising temperatures may be responsible for nearly , suicides in india in the past years (carleton, ) . farmers, in particular, are a highly vulnerable group for risk of suicide during times of drought (ellis & albrecht, ) , as farmers and other residents of drought areas have significantly higher levels of anxiety, emotional distress, and depression (clayton et al., ; coêlho, adair, & mocellin, ) . in fact, the more severe the drought, the greater the suicide risk, and projections suggest that this trend will only be exacerbated by rising temperatures (ding, berry, & bennett, ) . although a myriad of complex factors contributes to the connection between climate change and suicide, these emerging data nevertheless underscore the urgency of developing effective mitigation and adaptation strategies. climate-change induced disasters, particularly heatwaves, may also lead to the exacerbation of existing acute and chronic mental health conditions. a canadian study observed that extreme environmental temperatures contributed to the psychotic exacerbation of schizophrenia, with persistently high temperatures associated with a significant increase in hospital emergency room visits for patients with mental disorders (wang, lavigne, ouellette-kuntz, & chen, ) . similar detrimental outcomes as a result of heatwaves were found in england (page, hajat, kovats, & howard, ) , where researchers found that patients with psychosis and dementia have a markedly increased mortality risk during heatwaves. in vietnam (trang, rockl€ ov, giang, kullgren, & nilsson, ), a similar occurrence was noted with a dose-response effect between rates of mental hospital admissions and the length of the heatwaves. however, while the former study found especially strong evidence for the worsening of psychiatric disorders in elderly populations, the latter reported more substantial effects in younger populations. for this specific age group, frequent assessment of children's well-being, especially in preparation for climate change related disasters, can allow for the identification of possible mental health issues, such as anxiety in face of disaster, and early preventative measures (dean et al., ) . although the mechanisms of action underlying the association between climate change and the exacerbation of mental health conditions is currently unclear, several mechanisms have been proposed, including pre-existing lowered resiliency to adapt to natural disasters (majeed & lee, ) and the magnification of other ongoing stressors (cunsolo willox et al., ) . further research in this field is necessary to elucidate the biological and psychological mechanisms of action, an undertaking that is crucial considering the quickly rising temperatures caused by climate change. future climate change predictions point towards more frequent and dangerous weather events, likely leading to an increase in individuals and communities experiencing higher rates of occurrence and severity of mental health problems. furthermore, a majority of existing studies are case-studies or focused on the immediate, short-term effects of a climate change outcome. as more individuals suffer from mental health effects of climate change, adequate resources, additional healthcare providers, further research, and appropriate community responses are needed to meet the increasing needs of the affected communities. the prevalence of these climate-change-related mental health outcomes, including ptsd, anxiety, depression, and suicide, as well as the contribution of climate change to the spread of pandemics and diseases like covid- , underscore the need for policy and preventive solutions, as well as the expansion of the conversation surrounding climate change, so that the impacts on mental health and wellbeing are discussed and considered especially in disaster preparedness planning. the academy's position on mental health the american academy of nursing (academy) identifies mental health as an urgent public health issue and supports policies targeted towards delivering highquality mental and behavioral health care. these policies include removing reimbursement and coverage barriers for mental health screening, intervention, and treatment (priester et al., ) and supporting resource allocation for the systematic integration of behavioral healthcare and primary care (davis et al., ) . the academy urges support for governmental programs addressing mental illness, as well as for the empowerment, education, and training of healthcare professionals for mental health treatment and care (hanrahan, stuart, delaney, & wilson, ; naegle et al., ) . the academy promotes the mental health of families, elders, and other vulnerable populations in order to foster resilience, health, and well-being (betz et al., ; tilden, ) . the academy places emphasis on both adaptation and prevention. adaptation is centered around developing reactive policies to the climate change issues that we know are already occurring. some examples of adaptive strategies include providing counseling (hayes, blashki, wiseman, burke, & reifels, ) , advocating for removal of barriers in access and cost to mental health care in insurance plans (rowan, mcalpine, & blewett, ) , and conducting more research on existing populations of individuals who have been affected by climate change (hayes et al., ) . these strategies would allow investigators to better understand the scope of the problem and develop more efficacious solutions to help those affected. prevention encompasses taking steps to increase knowledge of the effects of climate change on mental health in the public and to prepare for possible hazardous climate events in order to minimize their impact on health and well-being. thus, advancing mental health awareness and planning within the context of climate change is necessary and urgent (berry, waite, dear, capon, & murray, ) . possible strategies include encouraging school counselors and workers in homes for the elderly to begin early monitoring of those possibly at risk for mental health issues (hayes et al., ) , increasing the patient capacity of hospitals, and equipping hospital staff with the skills necessary for attending to patients specifically experiencing mental health issues in the context of climate change (laderman, dasgupta, henderson, & waghray, ) . in fact, the american academy of nursing is one of the endorsing organizations for the us call to action on climate, health, and equity: a policy action agenda (health voices for climate action, ). to reduce the psychiatric suffering exacerbated by climate change, the following interdisciplinary, multilevel recommendations addressing the impact of climate change on mental health and well-being should be implemented by policy makers, researchers, and health professionals in governmental, academic, clinical, and community settings. more specific strategies are detailed below. improve access to mental health services through increased and strengthened community-based mental health facilities in underserved areas with high risk of disasters related to climate change. for example, coastal communities prone to hurricanes and rural west coast communities prone to severe wildfires require more mental health providers in these areas (centers for disease control and prevention, ). promote community-level mental health initiatives that target vulnerable populations, including children and the elderly, as well as low-income populations that have limited resources to build resiliency during and after climate-change related disasters. educate patients and families about the health risks of climate change and how to prepare for and protect themselves. treat patients for specific psychiatric syndromes associated with climate related traumas. increase access to these services by continuing to increase the number of people with adequate health insurance through medicare and medicaid (national alliance on mental illness, ; rowan et al., ) . with a documented rise in hospital psychiatric admissions during times of climate change events, climate change impacts will likely cause increases in the demand for healthcare professionals and staff, as well as stretch the capacity of care delivery. in addition to a need for adequate resources, there is a need for an increase in the number of health-care practitioners, counseling services, clinics, and other health-related facilities in high impact areas for climate change outcomes. as the number of climate change related events will undoubtedly increase through the years, the supply of health providers and services must increase to meet the demand. this is particularly important given that the homes and families of providers may also have been adversely impacted by a disaster. further, an improvement in communication between the emergency department and communitybased outpatient mental health services would ensure adequate treatment and support for discharged patients and may lead to lower rates of hospital readmission (doupnik, esposito, & lavelle, ) . finally, considering that the majority of emergency departments in hospitals do not currently have the capacity or culture to support individuals with mental health issues, further discussion on developing new approaches to improve mental health care in the emergency department is necessary (laderman et al., ) . emergency department staff should also receive special training on addressing mental health issues specifically in those affected by natural disasters. increase the federal research funding provided by the national institute of mental health (nimh) and/or the substance abuse and mental health services administration (samhsa) targeting at prevention and intervention strategies to reduce the impacts of climate change on mental health (mental health america, ; national institute of mental health, ; substance abuse and mental health services administration, ). as a whole, the effects of climate change on mental and physical health are greatly under-researched, and further studies are warranted. for example, research could focus on intervention programs for patients suffering mental health issues following climate disasters or prevention programs for building resilience to the effects of climate change among people with mental health issues. future research should broaden the scope to examine how the type, intensity, duration, and frequency of climate change events add to the burden of mental illness globally. the disproportionate impact on disadvantaged and marginalized groups should be emphasized, especially in children, adolescents, and the elderly. furthermore, more thorough research should be conducted on long term implications on mental health across disciplines and populations. in addition, as the climate refugee situation expands and families are forced to leave low-lying coastal regions or fire prone areas, more research will be needed regarding the psychological impacts on the refugees themselves and the care providers required to serve the large number of new clients. improve community preparation and response to climate change in order to prevent and reduce impacts on mental health across the lifespan. for children and adolescents, schools should support nurses and counselors in recognizing and monitoring of mental health concerns among students. frequent monitoring of students' well-being and periodically following-up with students after a climate change crisis can help reduce the effect on mental health. similarly, nurses, counselors, and social workers in nursing and retirement homes should be more vigilant and trained in assessing, recognizing, and ameliorating the effect of climate change on mental health issues in the elderly (zalon, ). the substance abuse and mental health services administration (samhsa) provides communities and responders with behavioral health disaster response plans and training that help them prepare, respond, and recover from disasters. furthermore, community leaders should receive training in psychological first aid to understand the core principles of normalizing stress reactions to abnormal events, identifying and educating public to expected reactions, assisting community leaders in creating sense of safety, calmness, self and community effectiveness, supporting social connections and cohesiveness and sense of hopefulness (hayes et al., ) . advocate for increased budgets for the department of homeland security to allow for improved disaster preparedness preparation, response to mental health issues, infrastructure redesign, and federal response teams that can respond quickly when local health systems are overwhelmed in a disaster (department of homeland security, ). educate the public about the importance of anticipating and addressing mental health issues related to climate change through the national institute of mental health (nimh). currently the brochure titled "helping children and adolescents cope with disasters and other traumatic events: what parents, rescue workers, and the community can do" (national institute of mental health) does not alert health care workers or the general public to anticipate mental health issues related to climate change. nimh can partner with other organizations devoted to climate change and mental health, including climate psychiatry alliance and climate and mental health caucus of apa, to educate the healthcare providers and the general public. this policy brief reflects the current state of climate science and recommended policy changes. given the complexity of the earth's ecosystem, we must implement best practices while being aware that priorities and strategies themselves will need to adapt and change as new threats emerge. the case for systems thinking about climate change and mental health advancing the development of the guidelines for the nursing of children, adolescents, and families: revision: process, development, and dissemination things to know about climate change and coronavirus with who climate lead dr. campbell-lendrum higher temperatures increase suicide rates in the united states and mexico crop-damaging temperatures increase suicide rates in india mental health services for children policy brief retrieved / / from psychological research and global climate change mental health and our changing climate: impacts, implications, and guidance psychological responses to drought in northeastern brazil examining relationships between climate change and mental health in the circumpolar north ptsd and depression in adult survivors of flood fury in kashmir: the payoffs of social support a qualitative study of patient experiences of care in integrated behavioral health and primary care settings: more similar than different president's fiscal year budget fortifies dhs operations, supports frontline personnel the importance of humidity in the relationship between heat and population mental health: evidence from australia beyond mental health crisis stabilization in emergency departments and acute care hospitals climate change threats to family farmers' sense of place and mental wellbeing: a case study from the western australian wheatbelt. social science & medicine incidence and risk factors for post-traumatic stress disorder in a population affected by a severe flood hurricane harvey and greater houston households: comparing pre-event preparedness with post-event health effects, event exposures, and recovery mental health is an urgent public health concern climate change and mental health: risks, impacts and priority actions u.s. call to action on climate, health, and equity: a policy action agenda trends in mental illness and suicidality after hurricane katrina tackling the mental health crisis in emergency departments: look upstream for solutions posttraumatic stress, anxiety, and depression symptoms among children after hurricane katrina: a latent profile analysis the impact of climate change on youth depression and mental health recovery from ptsd following hurricane katrina the federal and state role in mental health access to treatment. national alliance on mental illness. national institute of mental health. helping children and adolescents cope with disasters and other traumatic events: what parents, rescue workers, and the community can do funding. national institute of mental health a new scenario framework for climate change research: the concept of shared socioeconomic pathways temperature-related deaths in people with psychosis, dementia and substance misuse treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: an integrative literature review access and cost barriers to mental health care, by insurance status grants. substance abuse and mental health administration advance care planning as an urgent public health concern heatwaves and hospital admissions for mental disorders in northern vietnam destruction of habitat and loss of biodiversity are creating the perfect conditions for diseases like covid- to emerge acute impacts of extreme temperature exposure on emergency room admissions related to mental and behavior disorders in toronto the lancet countdown: tracking progress on health and climate change preparing older citizens for global climate change this policy brief represents the work of the environmental and public health expert panel, the health behavior expert panel, and the psychiatric, mental health, and substance abuse expert panel. key: cord- - kwfulqe authors: yue, jing-li; yan, wei; sun, yan-kun; yuan, kai; su, si-zhen; han, ying; ravindran, arun v.; kosten, thomas; everall, ian; davey, christopher g; bullmore, edward; kawakami, norito; barbui, corrado; thornicroft, graham; lund, crick; lin, xiao; liu, lin; shi, le; shi, jie; ran, mao-sheng; bao, yan-ping; lu, lin title: mental health services for infectious disease outbreaks including covid- : a rapid systematic review date: - - journal: psychological medicine doi: . /s sha: doc_id: cord_uid: kwfulqe the upsurge in the number of people affected by the covid- is likely to lead to increased rates of emotional trauma and mental illnesses. this article systematically reviewed the available data on the benefits of interventions to reduce adverse mental health sequelae of infectious disease outbreaks, and to offer guidance for mental health service responses to infectious disease pandemic. pubmed, web of science, embase, psycinfo, who global research database on infectious disease, and the preprint server medrxiv were searched. of reports identified, were included in this review. most articles of psychological interventions were implemented to address the impact of covid- pandemic, followed by ebola, sars, and mers for multiple vulnerable populations. increasing mental health literacy of the public is vital to prevent the mental health crisis under the covid- pandemic. group-based cognitive behavioral therapy, psychological first aid, community-based psychosocial arts program, and other culturally adapted interventions were reported as being effective against the mental health impacts of covid- , ebola, and sars. culturally-adapted, cost-effective, and accessible strategies integrated into the public health emergency response and established medical systems at the local and national levels are likely to be an effective option to enhance mental health response capacity for the current and for future infectious disease outbreaks. tele-mental healthcare services were key central components of stepped care for both infectious disease outbreak management and routine support; however, the usefulness and limitations of remote health delivery should also be recognized. the coronavirus disease pandemic is the largest threat to the world in this century (who, ) . to limit transmission, business and school closures are implemented, mass quarantines (brooks et al., ) are imposed and self-isolation and social distancing (kaplan et al., ) are highly recommended, and such measures have been implemented in almost all countries to differing extents (galea, merchant, & lurie, ; ho, chee, & ho, ; jung & jun, ; li et al., a li et al., , b . millions of people in the world have been infected, with ever increasing numbers under quarantine or in isolation. fear of illness, severe shortages of resources, social isolation, large and growing financial losses, and increased uncertainty will contribute to widespread psychological distress and increased risk for mental illness and behavioral disorders as a consequence of covid- (pfefferbaum & north, ) . the worldwide impact of the covid- pandemic on mental health has already been identified as including insomnia, anxiety, and depression among healthcare workers and other vulnerable populations tang et al., ; brooks et al., ; cao et al., ; gao et al., ; gonzalez-sanguino et al., ; holmes et al., ; king, delfabbro, billieux, & potenza, ; li et al., a li et al., , b shi et al., ; wang et al., a wang et al., , b wang et al., , c xiao, zhang, kong, li, & yang, ) . chinese healthcare workers exposed to the covid- pandemic reported symptoms of depression ( . %), anxiety ( . %), insomnia ( . %), and psychological distress ( . %) (lai et al., ) . these symptoms also manifest in the general population, whose prevalence of depression, anxiety, insomnia, and acute stress was . , . , . , and . %, respectively . similar types of symptoms have accompanied other infectious disease epidemics such as severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers), and ebola virus disease (evd) (ho et al., ; jalloh et al., ; pfefferbaum & north, ; vyas, delaney, webb-murphy, & johnston, ; wu et al., ) . people discharged from hospital after recovering from covid- have reported high rates of posttraumatic stress disorder (ptsd) (bo et al., ) . a systematic review showed that after severe coronavirus infection, the point prevalence of ptsd was . % ( % ci . - . ), depression was . % ( . - . ), and anxiety was . % ( . - . ) (rogers et al., ) . some mental health problems persisted for years with a quarter of sars patients having ptsd, and . % having depression years after experiencing sars (mak, chu, pan, yiu, & chan, ) . early detection and recognition of covid- -related psychiatric symptoms is pivotal for tailoring cost-effective accessible interventions. mental health responses could enhance coping and lead to recovery from this massive worldwide psychological trauma of covid- and the pandemic. given the developing situation with coronavirus pandemic worldwide, policy makers urgently need an evidence synthesis to produce guidance for the development of psychological interventions and mental health response. the aim of this paper is to synthesize the data on mental health services and interventions for the infectious disease epidemics, and to enhance knowledge and improve the quality and effectiveness of the mental health response to covid- and future infectious disease epidemics. we sought to include any articles focusing on mental health interventions or services applied specifically for infectious disease outbreaks. we searched pubmed, web of science, embase, psycinfo on may , using a combination of text words and mesh terms: (sars or severe acute respiratory syndrome or middle east respiratory syndrome coronavirus or middle east respiratory syndrome* or mers-cov or mers or middle eastern respiratory syndrome* or merscov* or coronavirus or coronavirus infections or coronavirus* or covid- or -ncov or sars-cov- or ebola) and (mental disorders or mental health or mental health programs or mental health services or public health services or emergency services psychiatric or emotional trauma or psychosocial interventions or psychiatric interventions or psychological treatment or psychotherapy). we also searched who global research database on covid- using the term 'mental health', and the preprint server medrxiv with search terms 'sars or mers or ebola or coronavirus or covid- ' and 'mental health' on april . articles about mental health services (e.g. mental health system, mental health measures or strategies) and specific types of psychological interventions for infectious diseases such as sars, mers, evd, and covid- were included in the present review. we excluded articles on the epidemiology of psychological impacts, mental health responses to other types of diseases, and non-english publications. all articles were independently screened for eligibility by two reviewers (syk and yw) on title and abstract. all full-text articles identified were reviewed by yjl and byp. for each retrieved fulltext article, we hand searched the article's references and examined possible additional studies. original intervention trials were independently critically appraised using the cochrane collaboration's quality assessment tool by two reviewers (ssz and yk) (higgins et al., ; higgins & green, ) . consensus was used to resolve any disagreements. review authors' judgments evaluated selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias. in all cases, an answer 'l' indicates a low risk of bias and an answer 'h' indicates high risk of bias. if insufficient detail was reported of what happened in the study, the judgment will usually be 'unclear' risk of bias. the pubmed, web of science, embase, and psycinfo search identified , , , and articles, respectively. the who global research database on covid- identified articles and medrxiv identified articles. there were articles left after removing those articles which were duplicates from the six searches. hand searching of full-text articles yielded one additional reference to include in this review. in total, eligible articles were included in this review (see fig. ), most focusing on covid- , followed by evd, sars, and mers. of the articles, one used a randomized controlled trial (rct), seven used quasi-experimental methods or pre-post intervention or quantitative interview, reported processes of the delivery of care but did not rigorously evaluate outcomes ( reports, commentaries, and reviews) (see table ). twenty-three articles described mental health practices and services for covid- [china ( ), south korea ( ), singapore ( ), italy ( ), and one each for canada, germany, usa, uk, malaysia, iran, australia, and spain], seven articles for evd [sierra leone ( ), liberia ( ), and usa ( )], one article for sars (hong kong, china), and one article for mers (south korea). four different mental health practices were reported in this systematic review, including mental healthcare systems, psychosocial interventions, specific responses of psychiatric hospitals and digital mental healthcare (see fig. table ). table summarizes the assessment of risk of bias for five controlled trials. the majority of the intervention trials showed a low risk of bias, or we were unable to determine the risk. one trial had low risk of performance bias and detection bias, one trial had high risk of selection bias, and we were unable to determine the risk for other trials. all five trials had low risk of attrition bias, reporting bias, and other biases. as the other records included in this review were not controlled trials or were commentaries, we did not conduct quality assessments for them. governments have variously developed interventions and response systems to deal with the mental health problems caused the mental health professionals provided psychological counseling to individuals in quarantine. national hospitals and community mental health centers also provided mental health care services. leaflets promoting mental health care for the distress caused by infectious disease outbreaks were distributed. percudani et al. italy covid- report (-) regional health authorities authorized the continuation of mental health services for the general population. safety guidelines for both medical staff and patients were implemented, including remote psychosocial interventions and telemedicine. hospital admissions for acute psychiatric disorders in patients positive for covid- need a dedicated area in the psychiatric ward or alternatively, a medical ward supported by psychiatric staff. (continued ) jing-li yue et al. ( ), their families ( ) the community-based mental health system of detection, brief intervention, and refer to treatment was established for the quarantined mers patients and their families. service utilization rate, . % receive one consultation, . % required continuing services, . % received continuing services. albott et al. ( ) small group cbt developed to treat anxiety, depression, and functional impairment, eight sessions over weeks. at post-intervention, anxiety, depression, and functional impairment significantly reduced, helping . % of the participants to their personal goals or recovery. overall, the intervention was given a mean rating of . out of by the participants. ping et al. malaysia covid- report nurses on the covid- frontline ( ) ultra-brief psychological interventions for month including group problem-solving techniques, mindfulness skills and so on. the informal qualitative feedback has suggested that it has helped respond effectively to individuals with anger or frustration, anxiety secondary to the uncertainty of the daily fluctuations of covid- , panic and tension in committee meetings, and the general psychological wellness of hospital staff. kazerooni et al. iran covid- report medical junior students ( ) near peer mentoring via the social media platform. senior students under the supervision of expert faculty offered psychological supports for junior students such as stress relaxation techniques, time management, etc. % of junior medical students believed the platform had a significant impact on helping them adjust faster to these emergency conditions. decosimo et al. sierra leone children who were ebolasurvivors; living in ebola-infected homes or community ( ) a community-based psychosocial arts program (playing to live). activities included storytelling, musical freeze dance, art drawing, yoga, and dancing. contrasted a -month to a -month treatment. significant decrease in reported symptoms in both treatment groups pre-to post-intervention and a significant difference in total symptoms over time. waterman et al. sierra leone evd quantitative interview ex-etc staff ( ) -week group cbt program for depression and anxiety modeled on evidence-based low-intensity interventions. barriers (lack of motivation to attend, low literacy) and enablers (novelty of cbt, social network). waterman et al. sierra leone evd pre-post intervention ex-etc staff ( ) three-phased cbt-based intervention. improvement of ptsd, sleep, depression, anxiety, and alcohol usage. sierra leone the general public, inpatients general nurses were trained in pfa, case identification and referral pathways and provided basic counseling and problem-solving therapy for individuals in the need of mental healthcare. kohrt et al. liberia evd pre-post intervention mhcs ( );law enforcement officers ( ) adapting the cit model implemented a national community-based anti-stigma program, family support and advocacy activities, and facilitated partnerships to advance mental health policy, legislation, and funding. the anti-stigma and advocacy activities involved work with journalists, pharmacists, religious leaders, and other stakeholders. there is a need to develop formal collaborations with law enforcement for stigma reduction, service provision, and human rights protection. there was a significant increase in knowledge ( - % of items answered correctly), a significant increase in positive attitudes, and a significant decrease in social distance. (continued ) jing-li yue et al. the 'strength-focused and meaning-oriented approach to resilience and transformation' intervention using a cognitive redefinition was applied. after the -day group debriefing, participants showed significant decrease in depression level and changes in cognitive appraisal toward sars. such changes were sustained in a -month follow-up. garriga et al. (yoon, kim, ko, & lee, ) . various mental health centers such as public health centers, community mental health centers cooperatively delivered services for mers patients and the national center for crisis mental health management evaluated people using these services and subsequently transferred them to local community mental health centers for continuing case management and follow-up. the service utilization rate was high, but they also found that the referral system from the national level to regional or local levels did not work well (yoon et al., ) . while active detection of subjects with emotional difficulties and interventions following the covid- outbreak was a potential option, they needed a more efficient process for an open entry system at the local level rather than a triage system starting nationally from the top. a series of mental health-related actions were taken at the initial stage of the covid- outbreak in china (li et al., , b qiu, zhou, liu, & yuan, ; wang et al., a wang et al., , b wang et al., , c yao, chen, zhao et al., ; zhou, ) , singapore (ho et al., ) , south korea (jung & jun, ; park & park, ; yoon et al., ) , canada (agyapong, ) , germany (bauerle, skoda, dorrie, bottcher, & teufel, ) , italy (percudani, corradin, moreno, indelicato, & vita, ) , and the usa (schreiber, cates, formanski, & king, ) . specifically, mental health professionals including psychiatrists, psychiatric nurses, and psychologists were deployed to provide psychological counseling and support for vulnerable populations (e.g. frontline healthcare workers, confirmed covid- patients, suspected covid- cases and their families) in china and for people in quarantine in south korea. the national health center of china (nhc) issued several guidelines and plans (nhc-china, b , c , d . several national associations related to mental health and academic societies cooperated to establish expert groups on psychological interventions to older adults (wang et al., a (wang et al., , c . psychoeducational books, articles, and videos were made available for the public through e-platforms and mobile apps (e.g. wechat) at the early stage of the covid- outbreak in china (bao, sun, meng, shi, & lu, ; li et al., a li et al., , b pfefferbaum et al., ) . several hospitals, individual psychiatric departments, community psychiatric partners, and psychologists all provided online psychotherapy and counseling to psychiatric patients and the general public with covid-related psychological distress through videoconferencing platforms (e.g. zoom) in singapore (ho et al., ) . leaflets for the general public provided guidelines for coping with the covid- distress and hotlines provided information for covid- mental health crisis that might occur in south korea (park & park, ) . canada launched a support text message (text mood) program to respond to the psychological impact of covid- . this program provided free psychological supportive text messages daily for months (agyapong, ) . germany's 'coping with corona: extended psychosomatic care in essen' (cope) offered psychological support for distressed individuals, which included four steps: initial contact, triage and diagnosis, support via tele-or video-conference, and aftercare. this program offered psycho-educational information materials about resources, relaxation techniques, and mental health (bauerle et al., ) . increasing public mental health literacy is vital to prevent and overcome the mental health crisis during the covid- pandemic. education and support from the voluntary and professional mental health sectors should be a part of mental health prevention under large infectious disease outbreaks. psychological and physical supports tended to be specifically matched to different vulnerable populations, such as children, older adults, and health care workers. a national community-based anti-stigma and advocacy activity, which is a curriculum based upon the crisis intervention team (cit) model was launched in liberia during the evd outbreak, could significantly decrease mental health and public health problems including violence, self-harm and suicide (kohrt et al., ) . a mental health unit was created at connaught hospital in sierra leone during evd outbreak (kamara et al., ) . general nurses were trained in psychological first aid (pfa), case identification, and referral pathways, and provided basic counseling and problem-solving therapy for individuals with mental healthcare needs. a nurse-led approach within a nonspecialist setting appears to have been successful for delivering mental health and psychosocial support (mhpss) services during the evd outbreak. peer support programs or services led by nonprofessional mental health workers are potential ways to deliver care in areas with limited human resources and weak social welfare systems. an alternate strategy which was employed during the sars outbreak in hong kong (ng et al., ) was the strength-focused and meaning-oriented approach to resilience and transformation (smart). this intervention employed a body-mind-spirit framework with a strong emphasis on cognitive redefinition of the stressful situation and the individual's response. results of the rct (n = ) suggested that participants' depression levels and adaptive changes in cognitive appraisal of sars decreased significantly after the single-day group debriefing. as this intervention trial included only a small sample, its efficacy needs to be replicated in a larger sample, and should include a follow-up study. for children and adolescents a community-based psychosocial arts program created by playing to live (ptl) was established for children who were ebola-survivors or living in ebola-affected homes or communities (decosimo, hanson, quinn, badu, & smith, ) . the ptl group hired and trained ebola-survivors to run the ptl activities two to three times a week in their communities. they also hired psychosocial workers to provide weekly supportive talks to families, and information about childcare and child rights. the ptl activities included storytelling, musical freeze dance, art drawings, yoga, and dancing. results of the pre-post-evaluation (n = ) suggested that the -month program was associated with a % reduction in symptoms including social withdrawal, extreme anger, bedwetting, worry/anxiety, poor eating habits, violence, and continued sadness, whereas the -month intervention group showed a % reduction of such symptoms. for older adults for mental disorders of old age, particularly dementia, there have been limited reports of the effects of the covid- pandemic. we found only one report on mental health care for older adults among our included papers. given the high death rate among older adults infected with covid- and the added strain on families with older relatives and on the institutions caring for them, the chinese society of geriatric psychiatry in collaboration with the chinese society of psychiatry responded with an interdisciplinary solution. mental health professionals, social workers, nursing home administrators, and volunteers collaboratively delivered mhpss for older adults, especially for community-dwelling residents and nursing-home residents (wang et al., a (wang et al., , c . mental health care for older adults during this epidemic was not given enough attention in the early stage of outbreak. more specific age-appropriate interventions may need to be developed for older adults for effective intervention during pandemic in the future. for healthcare workers frontline health care workers are also shouldering a greater mental health burden, and thus need support in strengthening their resilience through peer support and other interventions . first, proper protection against their own infection is critical. for example, masks, personal protective equipment, and other essential medical equipment (e.g. ventilators) will help relieve the stress of having to treat people with infections, and improve their mental wellbeing. during this covid- crisis, various interventions were offered to healthcare workers, such as a peer-supported resilience intervention in the usa (albott et al., ) , e-package with agile methodology in the uk (blake, bermingham, johnson, & tabner, ) , and the ultra-brief psychological intervention in malaysia (ping et al., ) . the e-package in the uk included evidence-based guidance, support, and signposting relating to psychological wellbeing, and results of this pre-post intervention (n = ) revealed that % of healthcare participants used the information in their work or home lives (blake et al., ) . feedback from healthcare workers suggests that qualitative wellness is improved by providing a free online resource manual targeting psychological skills and interventions to reduce the distress caused by uncertainty during the pandemic (ping et al., ) . many countries have developed dedicated teams to provide mental health support for healthcare workers; however, the type of support needed depends on the stage of the pandemic, and can benefit from peer and professional counseling (isaksson rø, veggeland, & aasland, ) . the anticipate, plan, and deter responder risk and resilience model was used to assess and manage healthcare workers' psychological risk and resilience during the evd outbreak (schreiber et al., ) . the anticipate, plan, and deter model contains three components. first, pre-deployment training about the stressors that healthcare workers may face during deployment ('anticipate'). second, development of a personal resilience plan ('plan') and monitoring stress exposure during deployment using the web-based system. third, invoking the personal resilience plan when risk is elevated ('deter'), addressing responder risk early before the onset of impairment. psychological support was offered to junior medical students in iran via a novel social media platform during the covid- (rastegar kazerooni, amini, tabari, & moosavi, ) . in total, % of participants (n = ) believed the platform had a significant impact on helping them adjust faster to these emergency conditions. following the evd outbreak in sierra leone, cognitive behavioral therapy (cbt) was widely used among ebola treatment center (etc) staff (cole et al., ; waterman et al., ; waterman, cole, greenberg, rubin, & beck, ) . results of the pre-post intervention (n = ) showed that small group cbt could significantly reduce anxiety, depression, and functional impairment of etc staff after eight sessions over weeks (cole et al., ) . workshops with different themes such as pfa, stress, sleep, depression, anxiety, relationships, and behavior were developed in phase and . participants still displaying high anxiety and depression levels after phase and were enrolled in phase with low-intensity cbt strategies. significant improvements in the stress, anxiety, depression, and anger domains were reported, but no improvement in sleep (waterman et al., ) . cbt is an evidence-based intervention delivered through various means besides face-to-face interactions. for example, delivery over the internet or smartphone apps can be efficient for broad outreach to the populations at risk for mental health complications. the feasibility and effectiveness of training a national team to deliver a three-phase cbt-based group intervention to ex-etc staff suggested that this model protected healthcare workers from negative psychological consequences of potentially traumatic stressors (waterman et al., ; waterman et al., ) . however, the effectiveness of this model and its components needs more rigorous evaluation, because it relied on a single small sample during a unique epidemic (schreiber et al., ) . furthermore, most of the reviewed studies were pre-post measurements with substantial heterogeneity in the included participants, methods, study designs, and outcomes. standardized evaluations in randomized clinical trials were difficult to implement due to the urgent nature of the pandemics. evidence-based interventions that have shown efficacy in conditions differing from epidemics also might be effective approaches to combat covid- , but their effectiveness needs to be tested in controlled trials during the covid- pandemic. psychiatric hospitals in china prepared to cope with the covid- outbreak by establishing crisis psychological intervention teams across many psychiatric hospitals, including psychiatrists, clinical psychologists, and psychiatric nurses (li et al., , b shao, shao, & fei, ; xiang et al., ) . a specialized psychiatric ward was established in an infectious disease hospital in wuhan on february , and in turn isolation wards were established in psychiatric hospitals for mentally ill patients with suspected or confirmed covid- . nhc issued a set of guidelines in february to standardize the management of patients with severe mental disorders during the covid- outbreak (nhc-china, f ). subsequently, the chinese society of psychiatry published guidelines to the hospital administration applicable to both psychiatric hospitals and psychiatric units in general hospitals during the outbreak (chinese society of psychiatry, ). psychiatric hospitals reduced outpatient visits, tightened admission criteria, and shortened the length of inpatient hospitalizations. for newly admitted psychiatric patients, isolation wards were set up and visiting was suspended to minimize the potential risk of nosocomial infection. additionally, the majority of psychiatric hospitals used telemedicine to provide psychiatric consultations for infected patients and medical treatments for patients with preexisting mental disorders, and antipsychotic drugs were often delivered to patients' homes following the covid- outbreak in china. the italian society of epidemiological psychiatry also issued operational instructions for the management of mental health departments and similar measures were employed in italy (starace & ferrara, ) . the institute of mental health (imh) in singapore implemented a series of prevention and control strategies at the levels of hospital, ward, and individual (poremski et al., ) . except for restrictions on patients and visitors, medical staff were managed effectively, for example, electronic tracking of staff movement to facilitate contact tracing in singapore (poremski et al., ) and china (shao et al., ) . for community care centers and out-patient clinics, in-person visits were recommended for patients with a psychiatric emergency, risk of psychiatric relapse or new emergent cases with mental disorders, incorporating phone call follow-ups and telepsychiatry consultations in spain (garriga et al., ) . as per in-patients, early discharges of the psychiatry emergency rooms and acute wards were moved forward and the suspension of family visits was implemented. a novel mental health home hospitalization care was recommended (garriga et al., ) . the infection control measures needed to limit potential exposure to sars-cov- led to inaccessibility of some mental health interventions such as injectable medications and electroconvulsive therapy, and the relative risks and benefits of these treatment losses need to be evaluated . these losses should be assessed in the balance with many novel strategies involving digital telemedicine, mental health home hospitalization, commercial drug delivery, and electronic tracking. moreover, follow-up studies are needed on how effective these interventions were in mitigating the mental health impacts of other losses to mental services and patients. tele-mental health services were prioritized for individuals at higher risk of exposure to covid- infection such as frontline clinicians, infected patients, suspected cases of infection, their families, and policemen. there are well-documented reports of china proactively providing various tele-mental health services during the covid- outbreak zhou et al., ) . the nhc and the chinese psychological society provided guidelines on conducting online mental health services (li et al., , b nhc-china, a . these services were provided by the government, academic agencies (e.g. hospitals, universities, institutes), associations of mental health professionals, and non-government organizations. the services included counseling, supervision, training, as well as psychoeducation through e-platforms (e.g. hotline, wechat, weibo, tencent qq, alihealth, and haodaifu) (moe-china, ) . additionally, online self-help psychological interventions such as cbt for depression, anxiety, and insomnia were also developed . early reports indicated high interest and acceptance of these services by the target population. the 'national crisis intervention platform for covid- ' was created with mental health professionals. several hospitals set up their own crisis counseling system for staff and patients using telehealth in many provinces of china kang et al., ) . the australian government had delivered a wide range of telehealth services including telehealth consultations to general practitioners and specialists . however, to date, the australian government has focused on managing the physical health needs of the population during the epidemic, with less focus on mental health . access to other existing tele-mental health support services such as self-help platforms, videoconferencing, or mobile apps for depression, anxiety, and emotional problems should be made available for the general population . telehealth has become a cost-effective alternative for delivering mental health care during the covid- global pandemic when in person and face-to-face visits are not possible. solid evidence supports the effectiveness of telephone and web-based interventions, especially for alleviating symptoms of depression, anxiety, and ptsd (kerst, zielasek, & gaebel, ; turgoose, ashwick, & murphy, ) . videoconferencing, online programs, smartphone apps, text-messaging, and e-mails have been useful communication methods for the delivery of mental health services (torniainen-holm et al., ; zhou et al., ) . national and provincial digital mental health services (e.g. hotlines, websites, wechat, weibo) have been established as essential measures to address mental health needs of key target populations such as healthcare providers during the covid- outbreak. however, digital therapies might not be appropriate for older or demented people, people with reading difficulties, poor people, or people who are not technologically adept. the combination of online and offline psychological counseling is a key strategy for mental health services and intervention systems during the covid- pandemic. this paper provides a rapid review of the published literature on mental health practices and services during recent infectious disease epidemics. except for publications on some mental health intervention systems and psychosocial interventions, most other reports were not specifically designed to evaluate the feasibility and effectiveness of mental health interventions. more evidencebased psychosocial interventions with telehealth services and considering contextual adaptation, complexity, and resources requirements are needed during the covid- pandemic and future outbreaks of infectious diseases. during infectious disease outbreaks such as covid- , measures implemented for their prevention (e.g. quarantine and isolation, business or school closures) as well as the losses induced by them (e.g. finance, food, personal freedom, social connection, and relationships) contributed to significant emotional distress, reduced mental well-being, and may lead to psychiatric or behavioral disorders in both the short and long term. these consequences are of sufficient magnitude, requiring immediate efforts and direct interventions to reduce the impact of the outbreaks at both individual and population levels (galea et al., ) . psychoeducation and emotional support in particular help to normalize crisis reaction, mobilize resources, and increase adaptive coping strategies for progression to serious mental illness such as major depression or ptsd (north & pfefferbaum, ; north, hong, & pfefferbaum, ; reyes, ) . however, many countries have tended to focus on the physical health needs of covid- , often neglecting mental health needs with few designated organizations offering specific mental health services with easy access to those in need. the integration of mental health provisions into the covid- (and other infectious disease emergencies) response should be best addressed at the national, state, and local planning levels (pfefferbaum & north, ) . call for evidence-based psychosocial interventions to cope with the covid- pandemic prevention efforts in mental health were implemented primarily for people who were at risk or had greater vulnerability, such as frontline workers, confirmed covid- patients, infected family members, and those affected by the loss of loved ones (holmes et al., ) . mhpss programs through international organizations were used effectively in several low-and middle-income countries during infectious disease outbreaks (cenat et al., ) . for example, group-based cbt (waterman et al., ; waterman et al., ) , pfa, ptl (decosimo et al., ) , culturally adapted interventions such as smart (ng et al., ) , ultra-brief psychological interventions (ping et al., ) and peer supports (rastegar kazerooni et al., ) have been reported to effectively mitigate the emotional impacts of covid- , evd, and sars outbreaks. however, the quality of evidence was still restricted because limited studies have provided quantitative data, and most intervention studies included small numbers of participants. during the covid- pandemic, other evidence-based interventions can be applied, and their feasibility and effectiveness should be evaluated. for example, mindfulness-based interventions (hofmann & gomez, ) or cbt for insomnia (koffel, bramoweth, & ulmer, ; riemann et al., ; trauer, qian, doyle, rajaratnam, & cunnington, ) can be assessed for their effectiveness in the provision for individuals suffering from severe sleep problems or chronic anxiety symptoms. psychosocial interventions can provide support for individuals in the wake of a crisis and can increase the perceived safety of individuals, further ameliorating maladaptive stress reactions and reducing emotional distress (slavich, ) . people with major losses or those with more severe illnesses are more vulnerable to experience depression, suicidal ideation, or ptsd in the initial phase of the pandemic or even after it ends (north, suris, davis, & smith, ). evidence-based trauma-focused psychotherapies and pharmacotherapy are appropriate. for specific subgroups, family intervention may be recommended (dawson et al., ; forbes et al., ; north & pfefferbaum, ) . facing the pandemic, measures for identifying, triaging, referring, and treating severe psychosocial consequences, death notification, and bereavement care should be established (north & pfefferbaum, ; pfefferbaum & north, ; . moreover, for the lower income countries, with greater scarcity of mental health resources, implementation or modification of evidence-based psychological treatments, such as psychological treatments to be delivered by non-specialist providers including through task sharing, is urgently needed (barbui et al., ; singla et al., ) . evaluating the effectiveness of interventions to mitigate covid- 's mental health consequences on patients the degree of risk for infection with covid- for individuals with severe mental illnesses has not been clearly established; however, it is reasonable to presume such risk to be higher than that of the general population, because of disordered mental state, possible poor self-care, inadequate insight, or side effects of psychotropic medications (starace & ferrara, ; xiang et al., ) . furthermore, adverse social determinants brought about by the covid- pandemic, including poverty, food insecurity, and stigma, can be contributory (lund et al., ) . people with severe mental health problems commonly live in poverty which impacts their ability to socially distance themselves from neighbors or the local community and increases transmission risk. psychiatric inpatients confirmed or suspected covid- could be treated in specialized wards in infectious disease hospitals or in isolated wards in psychiatric hospitals or shelter hospitals equipped with psychiatric consultations. as for psychiatric hospitals, measures including strict triaging/precautionary procedures and admission criteria, and shorter hospitalization length of stay should be taken to prevent the clustering of covid- cases (chinese society of psychiatry, ; shao et al., ; starace & ferrara, ) . additionally, mental health home hospitalization care was recommended (garriga et al., ) , and medical staff management in psychiatric hospitals such as electronic tracking of staff movement might facilitate contact tracing (poremski et al., ) . however, follow-up studies on how effective these interventions were in mitigating covid- 's mental health impacts on mentally ill patients are needed. these studies should balance the risks and benefits of these alternative interventions on mental health services among patients and providers. the potential of digital therapy programs which can offer costeffective evidence-based therapies has not been fully realized. however, awareness of the disparities in access to the technology of poorer populations and cultural and linguistically diverse communities in low-and middle-income countries may have an impact on their implementation (naslund et al., ) . the effectiveness of digital mental health interventions in such countries has not been rigorously evaluated. online mental health services' utilization is still low in china and australia . however, telehealth remains a valuable way of reducing psychosocial distress without increasing the risk of infection. during infectious disease outbreaks, telemental health services can enable remote triaging of care, offer cognitive and/or relaxation skills to deal with stress symptoms, encourage access to online self-help programs, and deliver professional psychological interventions if necessary. simple communication methods such as e-mail and text messaging can and should be used more extensively in low-income countries. however, many of these interventions require more rigorous jing-li yue et al. assessments to determine their efficacy, effectiveness, treatment retention, and outcomes. investing in the collection of evidence on the outcomes, workforce requirements, patient engagement, and ethical uses of tele-mental health services will allow them to truly deliver their full potential . telehealth and digital services should not completely replace face-to-face treatment for patients in need, particularly those requiring intensive mental health treatment and support including wider deployment of injectable long-acting medications and hands-on interventions such as electroconvulsive and transcranial magnetic stimulation therapies, when in-person contact is once again safe. several limitations of this systematic review need to be considered. first, few rcts on the effectiveness of mental healthcare interventions on mitigating mental problems during any of these infectious disease outbreaks were identified, and more highquality rct studies are needed. second, due to the limited number of studies on psychological interventions during infectious disease outbreaks, and the heterogeneity of evaluation methods, we only could provide a systematic review without a formal meta-analysis. third, relatively few countries have reported mental health services and treatments during infectious disease outbreaks, more high-quality studies are in need to form culture-adapted efficient and nationally unique mental health responses for infectious disease outbreaks. the pandemic of covid- brings huge challenges for mental health systems worldwide which have to rapidly change, but also can offer an opportunity for improvement of mental health responses, and lead to long-term development of sustainable mental health care systems. despite differences in political, social, and health systems, mental health services worldwide have implemented acute responses that focus on care for mental health service users, and have facilitated access to mental health assessment and care for new-onset or high-risk patients. more evidencebased interventions should be implemented during epidemics especially for vulnerable populations such as children, older adults, and healthcare workers. the effectiveness of alternative digital interventions in mitigating the mental health consequences on mental services and patients should be assessed in follow-up studies. tele-mental health strategies and global cooperation are sound approaches to develop and implement 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coronavirus disease (covid- ) outbreak in january in china rethinking online mental health services in china during the covid- epidemic mitigating mental health consequences during the covid- outbreak: lessons from china system effectiveness of detection, brief intervention and refer to treatment for the people with posttraumatic emotional distress by mers: a case report of community-based proactive intervention in south korea psychological crisis interventions in sichuan province during the novel coronavirus outbreak the role of telehealth in reducing the mental health burden from covid- acknowledgements. we appreciate an-yi zhang, yi-jie wang, xiao-xing liu, xi-mei zhu, ze yuan, chen-wei yuan and meng-ni jing for their help with the data search. conflict of interest. none. key: cord- - a avlro authors: hou, tianya; zhang, taiquan; cai, wenpeng; song, xiangrui; chen, aibin; deng, guanghui; ni, chunyan title: social support and mental health among health care workers during coronavirus disease outbreak: a moderated mediation model date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: a avlro purposes: during the outbreak of coronavirus disease (covid- ) all over the world, the mental health conditions of health care workers are of great importance to ensure the efficiency of rescue operations. the current study examined the effect of social support on mental health of health care workers and its underlying mechanisms regarding the mediating role of resilience and moderating role of age during the epidemic. methods: social support rating scale (ssrs), connor-davidson resilience scale (cd-risc) and symptom checklist (scl- ) were administrated among health care workers from jiangsu province, china during the peak period of covid- outbreak. structural equation modeling (sem) was used to examine the mediation effect of resilience on the relation between social support and mental health, whereas moderated mediation analysis was performed by hayes process macro. results: the findings showed that resilience could partially mediate the effect of social support on mental health among health care workers. age group moderated the indirect relationship between social support and mental health via resilience. specifically, compared with younger health care workers, the association between resilience and mental health would be attenuated in the middle-aged workers. conclusions: the results add knowledge to previous literature by uncovering the underlying mechanisms between social support and mental health. the present study has profound implications for mental health services for health care workers during the peak period of covid- . a a a a a the coronavirus disease (covid- ) as an unprecedented threat has infected more than , , people by april, [ ] , which has attracted international attention as a public health emergency of international concern [ ] . considerable countries are confronting escalating pandemics and tremendous burden. the availability of skilled health care workers is the decisive factor in overcoming a viral epidemic [ ] . in the most affected areas such as hubei province, china where the confirmed cases were first reported, nearly all health care workers work directly with the infectious patients, whereas in the less affected areas, some health care workers directly fight against covid- and others are prepared to fight. however, the bravery of health care workers cannot protect them away from mental health problems during covid- . according to the research during the severe acute respiratory syndrome (sars) outbreak, health care workers have shown mental health problems with % hospital workers reporting higher levels of stress [ , ] . another study during ebola outbreak presented that health care workers of sierra leone had significant psychological symptoms including depression, interpersonal sensitivity and even paranoid ideation [ ] . more importantly, evidence from previous literature showed that the stress levels for high-and low-risk health care workers were equivalent during the outbreak of epidemic [ ] . psychological intervention and mental health services were in need to prevent health care workers from being traumatized as they were emotionally affected during the epidemic [ , ] . mental health is fundamental to an individual's overall well-being and absolutely essential to a productive and efficient life. in workplace, mental health problems are found to be associated with plenty of negative influences, such as reduction of efficiency, loss of productivity, disability and absenteeism [ , ] . given the adverse impacts, it is of great importance to investigate the potential factors and mechanisms that could enlighten the improvement of the mental health and maintenance of productivity of health care workers in the mist of the epidemic. among all the influential factors, social support has been recognized as one of the protective factors for mental health [ , ] . thus, the aim of the present study was to replicate the relationship between social support and mental health based on the health care workers during covid- outbreak, and further extend the previous studies by exploring the potential mechanisms in the relationship. social support is individuals' perception or experience in terms of being involved in a social group where people mutually support each other [ ] . previous research has repeatedly emphasized the role of social support in the promotion of mental health [ ] . not only crosssectional studies [ , ] , but also a large body of longitudinal studies emerging recently [ , ] have confirmed the positive association between social support and mental health outcome robustly. although a substantial number of research found this strong relation can hold across a broad range of samples, such as cancer patients, patients with multiple sclerosis, nurse students and so on [ , , ] , a handful of studies have presented different results. a meta-analysis conducted by ge, zhao, liu, zhou, guo & zhang [ ] has concluded that for the aged people, mental health was weakly or extremely weakly associated with social support. fiori et al. [ ] has claimed that the emotional support was only related to mental health in females only, not in males. therefore, it is vital to note the previous studies have found the relation between social support and mental health based on certain samples, however, whether the conclusion could be duplicated to health care workers during the outbreak of covid- still remains unexplored. moreover, the mediating mechanisms (i.e., how social support correlates with mental health?) and moderating mechanisms (i.e., when this relationship is most potent?) underlying the association between social support and mental health also stay largely unknown. answering these questions could be of vital importance to further understand the mental health of medical workers and advance the more effective interventions to ensure the productivity of health care worker during covid- . thus, the present research employed a sample of chinese health care workers during covid- outbreak to explore a conceptual model in which, on the one hand, resilience mediated the association between social support and mental health; on the other hand, the indirect relationships between social support and mental health via resilience were moderated by age group. social support and resilience. resilience is an individual's capacity to deal with significant adversity and quick recover [ ] . a great many of studies based on various methodologies and samples have provided robust evidence with respect to the association between social support and resilience. numerous cross-sectional studies have revealed a positive association between social support and resilience [ ] [ ] [ ] . in addition, a longitudinal study conducted by liu, he, jiang, & zhou [ ] utilized a sample of adolescents from . earthquake-hit region and confirmed social support as the protective factor of resilience after a one-year followup. furthermore, a meta-analysis including studies also has concluded that social support, particularly the utilization of the support, could enhance children's resilience [ ] . thus, it is possible that social supports could enhance the resilience of health care workers. resilience and mental health. mental health is the critical component of personal development and growth, which is more than the absence of mental illness [ ] . plenty of empirical studies reach the consensus that resilience exerts an positive effect on mental health [ ] [ ] [ ] and the association is presented to be consistent across different samples with diverse background [ ] [ ] [ ] . also, psychological resilience can help protect individuals against mental illness and thrive from the adversity [ ] . in fact, a few researchers have investigated the relation between social support, resilience and wellbeing [ , , , ] . it is worth noting although the previous studies explored the relation, some treated resilience as a covariate or moderator, while others did analyze resilience as a mediator. however, as far as we know, no research has examined whether the relationship between social support and mental health via social support could be applied to the health care workers who are prepared and fight during the epidemic. although social support may have an impact on mental health indirectly via resilience, not all people with lower resilience suffer from lower level of mental health. therefore, it is essential to explore the influential factors that could strengthen or attenuate the link between social support, resilience and mental health. this research examined a hypothesis that the resiliencemental health link in the indirect association between social support and mental health would be moderated by age group. several studies have concluded the possibility of the receipt of depression treatment diminished as getting older [ , ] . robb, haley, becker, polivka & chwa [ ] have compared the similarity and difference between younger and older adults in the attitudes towards mental health service, and found younger adults showed more willing to seek mental health services compared with the elder. in addition, dinapoli, cully, wayde, sansgiry, yu, & kunik [ ] have examined the role of age in the prediction of mental health service use. the results have presented that younger adults with depression or anxiety disorders were more likely to utilize mental health service compared with the middle-aged adults. the mental health services include mediation, yoga and stress management, which are mainly focusing on the enhancement of resilience [ , ] . in sum, younger adults might be more likely to receive resilience training to improve the mental health than middle-aged adults. thus, the mental health of younger adults might rely more on resilience than other factors. furthermore, health care workers during the pandemic are in highly psychological stressing condition when fighting against covid- outbreak [ ] . the middle-aged workers usually have longer length of employment and more working experience than the younger workers. meanwhile, the odds of participation in the fight against other epidemics before might be higher for the middle-aged in comparison to the younger. all these past experiences would make them less stressful, less anxious, less fearful and better mental health state when facing the epidemic [ ] . taken all together, the mental health of the middle-aged workers would be less dependent on resilience, which indicates the link between resilience and mental health would be attenuated in middleaged adults than younger adults. in fact, a meta-analysis including studies has specifically investigated the moderating role of age in the relation between trait resilience and mental health [ ] . however, the study just concluded the relation was stronger for adults than children and adolescence, without the comparison between younger adults and middle-aged adults. unlike the previous research, the current study examined the potential difference between the younger and middle-aged medical workers in the link between resilience and mental health. taken all together, the aims of this research were twofold: (a) to examine whether the mediating role of resilience in social support and mental health could be duplicated to the health care workers from a less affected area during the covid- epidemic, and (b) to test whether the relationship between social support and mental health via resilience is moderated by age group. the current study constructed a conceptual model to address both mediation and moderation effects (see fig ) . based on the literature review, the following hypotheses were proposed: hypothesis : resilience would mediated the relationship between social support and mental health of health care workers during covid- pandemic. hypothesis : age group would moderate the indirect association between social support and mental health via resilience such that the resilience-mental health pathway would be stronger in younger age group in comparison with the middle-age group. given that we suppose age would only moderate the second stage of the mediation path, the present study would call it "a second stage moderation model". the cross-sectional study was conducted from st to th february, , which was the peak period of covid- outbreak in china. the participants were health care workers from local hospitals, community health service centers and government department in jiangsu province who participated in the fight against covid- . the questionnaires were distributed through internet. all subjects were given informed written consent before completing the online survey concerning demographic information, social support, resilience and mental health. all the subjects were free to withdraw from the research at any time. the research was approved by the ethics committees of the second military medical university. a total of health care workers completed the survey in the present study. considering the present study was to compare the indirect effect of social support on mental health via resilience between the young and middle-aged heath care workers, participants aged or over were excluded. finally, subjects were included in the analysis. social support. the social support rating scale (ssrs) developed by xiao was utilized to measure social support [ ] . the -item scale consists of dimensions including objective support, subjective support and availability. a representative item was "how many close friends do you have to get support and help?". higher scores indicate higher levels of social support. the scale has presented impressive validity and reliability in chinese population [ ] . the cronbach's alpha for the present study was . . resilience. the connor-davidson resilience scale (cd-risc) was used to assess resilience [ ] . the -item likert scale consists of five dimensions: (a) personal competence, high standards, and tenacity; (b) trust in one's instincts, tolerance of negative affect, and strengthening effects of stress; (c) positive acceptance of change and secure relationships; (d) control; (e) spiritual influence [ , ] . participants rated each item from (not true at all) to (true all the time). the range of total scores is from to , with higher scores representing higher levels of resilience. the scale has presented good psychometric properties [ ] . in this study, the cronbach's alpha was . . mental health. symptom checklist (scl- ) developed by derogatis and cleary [ ] was administrated to evaluate mental health [ , ] . the -item scale is widely applied to measure clinical psychiatric symptoms and differentiate individuals with mental illness from healthy people [ , ] . each item is rated from (no symptom) to (severe symptom). the higher total scores the participants got, the worse mental health condition they were in. in this research, scl- � was defined as psychological abnormality [ ] . the scale has shown good validity and reliability in chinese population [ ] . in this research, the cronbach's alpha was . . firstly, the present study calculated the descriptive statistics and bivariate correlations among variables of interest by statistical package for social science (spss) . for windows. a twotailed p-value smaller than . indicated the presence of statistical significance. secondly, structural equation modeling (sem) conducted by amos . through maximum likelihood method was performed to examine the mediating role of resilience in the relation between social support and mental health. the model fit index included root mean square error of approximation (rmsea), standardized root mean square residual (srmr), goodness of fit index (gfi) and comparative fit index (cfi). as recommended by previous literature, the values of rmsea and srmr smaller than . and the values of gfi and cfi more than . indicate an acceptable fit [ ] . bias-corrected bootstrap method was used to examine the significance of mediation effect. specifically, we used bootstrap samples and determined the bias-corrected % confidence interval. if the confidence does not contain zero, it means the significance of the effects [ ] . finally, the moderated mediation model was tested by using hayes [ ] process macro (model ). the % bias-corrected confidence interval from resamples was generated by bias-corrected bootstrapping method to examine the significance of moderated mediation effect. the sociodemographic characteristics of the participants and the distribution of scl- scores were presented in table . most health care workers were females ( . %), middle-aged ( . %), married ( . ), and reported - years of schooling ( . ) and less than years of working ( . ). the prevalence of psychological abnormality was % among health care workers. the mean ± sd total score of scl- was . ± . . there were no significant differences in scl- scores associated with gender, age, marital status, years of schooling and years of working. social support was positively correlated with resilience and age group, and negatively correlated with scl- scores (all p < . ). resilience was positively associated with age groups and negatively associated with scl- scores (all p < . ). structural equation model was employed to examine the mediating role of resilience. firstly, the direct path coefficient from social support to scl- scores in the absence of resilience was significant, γ = - . , p < . . secondly, the structural equation model regarding the ) . a bootstrap procedure conducted to examine the mediation effects. bootstrapping samples was generated from the original dataset (n = ) via random sampling. the indirect effect of social support on scl- scores through resilience was - . (se = . , %ci = [- . , - . ], p = . ). the % biased-corrected confidence interval did not contain zero, which verified the indirect relationship between social support and scl- scores via resilience. it has been expected that age group would moderate the second stage of the mediation process. as shown in table , in model , social support positively predicted resilience, β = . , p < . . model revealed that the effects of resilience on scl- scores was moderated by age group, β = . , p < . . for descriptive purpose, the present study plotted the relationship between resilience and scl- scores, separately for younger and middle-aged groups (see fig ) . simple slope test presented that for subjects from younger group, resilience was significantly and negatively associated with scl- scores, β simple = - . , p < . . for subjects from middle-aged group, resilience was still negatively correlated with scl- scores, but much weaker, β simple = - . , p < . . the biased-corrected % confidence interval for index of moderated mediation was from . to . , which did not contain zero. this further presented that the indirect effects of social support on scl- scores via resilience significantly differed between groups. evidence from previous literature has already found health care workers with higher levels of social support are more likely to show higher levels of mental health [ , ] . nevertheless, issues regarding the underlying mediating and moderating mechanisms and whether this could be applied to health care workers who are fighting with the outbreak of covid- stay largely unanswered. to our knowledge, the present study is the first to report the effect of social support on mental health based on health care workers from a less affected area during covid- outbreak. this research built a moderated mediation model to test whether resilience mediated the association between social support and mental health of health care workers and whether this indirect relationship was moderated by age groups. the results showed that ( ) the mediating role of resilience in the association between social support and mental health could be replicated to the health care workers during the epidemic; ( ) age moderated the indirect link between social support and mental health (resilience-mental health path), with younger workers showing stronger than middle-aged workers. the prevalence of psychological abnormality was % among health care workers in our study, lower than that ( . %) of chinese health care workers during the sars epidemic [ ] . a recent study presented the rate of mental abnormality among nurses in guangdong province was . % during the non-epidemic phase [ ] . the difference might be attributed to the fact that jiangsu province was less affected during the covid- pandemic. additionally, different instruments and regional differences might also contribute to the discrepancy. generally speaking, the prevalence of psychological abnormality cannot be neglected and more attention should be paid to address this issue. in line with our hypothesis, resilience mediates the relationship between social support and mental health of health care workers during the epidemic. this is aligned with previous research based on different samples [ , ] . this study is the first to explore the relation with the focus on the population who are facing the emergency events of the public health. this finding can be explained by the "buffer" hypothesis developed by cohen and wills [ ] , which revealed the buffering effect of social support on the impact of stress upon mental health. the previous research has highlighted that finding effective approaches to deal with stress is of great importance in positive health outcomes [ ] . social support could protect individual from stressful conditions and poor health state [ ] . meanwhile, individuals with higher levels of social support might be more inclined to believe that they could get the help needed when facing the stressful event regarding the outbreak of the epidemic. this notion would enhance their beliefs to deal with the adversity and difficulty in the battle with covid- , which further leads to the higher levels of resilience [ ] . in addition, the reports of previous literature have demonstrated that resilience, as one kind of personal resources, also buffered the impact of stress on mental health [ ] [ ] [ ] [ ] . taken all together, resilience plays a mediating role in the association between social support and mental health for the health care workers fighting with the epidemic. the findings also revealed the moderating role of age groups in the association between resilience and mental health of the health care workers. in the past research, a small handful of previous studies have found that age moderated the link between resilience and mental health by the comparison between younger adults and older adults (usually age and over) [ , ] , whereas some other researchers focused on the contrast between the adults and minors [ ] . however, these studies neglected the potential differences between the younger adults and middle-aged adults. unlike the past research, this study took the potential difference between younger and middle-aged health care workers into consideration innovatively. consistent with our hypothesis aforementioned, the increase in age (from young adults to middle-aged adults) attenuated the relationship between resilience and mental health. specifically, the younger health care workers showed stronger association between resilience and mental health compared to the middle-aged ones. this result might be interpreted by erikson's theory of life cycle development [ ] , which postulates eight stages of human life. younger adults belong to stage vi with the emphasis on intimacy, while middle-aged adults are attributed to stage vii focusing on generativity. erikson's generativity stage is similar to self-actualization in maslow's hierarchy of needs [ , ] . hence, compared with younger adults, the mental health of middle-aged adults relies less on resilience but other factors, such as the feeling of self-fulfillment, personal growth and so on. the findings of this research have profound implications since the data were collected during the peak period of covid- in china, which is the stage other countries are currently experiencing. first, the results stress the crucial role of social support in mental health. during the outbreak, the maintenance of mental health of health care workers is crucial for the productivity and work efficiency. therefore, it is of great importance to provide a full range of social support including instrumental support, emotional support and so on. second, the findings also highlight the potential value of resilience-focused intervention in health care workers. the resilience-focused mental health promotion program usually contains coping skills, stress management, positive attitude and so on [ ] . finally, the indirect link between social support and mental health via resilience is stronger in younger adults, which implies we should give priority to younger health care workers with respect to resilience-boosting intervention. meanwhile, we also need to find other influential factors of mental health for middle-aged health care workers. several study limitations must be noted. first, the current study employed a cross-sectional design since health care workers who have consecutively worked for several days would be replaced by others, which made it hard to revisit them after a certain period. however, the cross-sectional design is insufficient to infer the causality in terms of the relationship analyzed. also, as existing literature showed, social support and resilience might influence each other reciprocally [ , ] , the reverse causality cannot be ruled out. future research could conduct longitudinal study to further explore the moderated mediation model. second, the study used convenient sampling and all data were collected through self-report, which undermined the generalization of the results. the participants in our study were all from jiangsu province, china, which was geographically limited for a wider generalization. future research could test the relation based on more typical samples from multiple regions and manage to collect data from multiple sources (e.g., colleagues). finally, mental health is a complex concept, which could be influenced by numerous factors. social support and resilience could just explain a limited part of mental health. sleep quality and fatigue might be two important factors of mental health, but we failed to investigate. during the covid- outbreak, health care workers had to work excessive hours and suffered from disrupted circadian rhythms, which would contribute to fatigue and undermine sleep quality. hence, future study might focus on a more integrated model of mental health with diverse influential factors. in spite of the limitations, the current study contributes to the previous literature theoretically and practically. theoretically, this study adds knowledge to the previous research by exploring the moderated mediation model, which would help further understand the relationship between social support and mental health. practically, the findings are essential for the maintenance of mental health of health care workers during the outbreak of covid- . in conclusion, this study presented the protective role of social support in mental health among health care workers. moreover, resilience could be one of the pathways through which social support contributes to mental health. furthermore, the effect of social support on mental health via resilience is attenuated in middle-aged health care worker compared with the younger ones. supporting information s file. 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motivation and personality generativity versus stagnation: an elaboration of erikson's adult stage of human development systematic review of resilience-enhancing, universal, primary school-based mental health promotion programs the influence of the resilience on the organizational commitment of kindergarten and childcare teachers: social support as a mediating variable the authors would like to acknowledge all participants and the research assistants from naval medical university. key: cord- - uv b authors: sloan, carlie j.; mailick, marsha r.; hong, jinkuk; ha, jung-hwa; greenberg, jan s.; almeida, david m. title: longitudinal changes in well-being of parents of individuals with developmental or mental health problems date: - - journal: soc sci med doi: . /j.socscimed. . sha: doc_id: cord_uid: uv b a large body of work demonstrates the impact of caregiving burden on the well-being of parents of individuals with developmental conditions or mental health problems. however, a relative dearth of research examines this impact longitudinally into parents' older age. objective. the current study examines ( ) longitudinal changes in the effect of having a child with a developmental or mental health problem on parental negative affect, psychological well-being, and somatic symptoms, ( ) age and gender moderations on these effects, and ( ) the unique impact of factors related to the child's condition. method. this study employs hierarchical linear regression models to examine longitudinal survey data from midlife adults (n = , ) from two waves of the national study of midlife in the united states (midus). results. models revealed some evidence for age attenuation of the impact of caregiving stress. parents of children with developmental problems still had higher negative affect, poorer psychological well-being, and more somatic symptoms on average than parents in a comparison sample, whereas parents of children with mental health problems only showed evidence of higher negative affect compared to this sample. within-group analyses also revealed differences between each parenting group into later adulthood. conclusions. parents of individuals with developmental or mental health problems may be at risk for poorer well-being late in life. yet, age and gender differences as well as diagnostic group differences nuance these findings. parenting a child with a developmental or mental health problem can be a significant source of stress. the effects of caring for a child with one of these diagnoses on parental wellbeing have been documented across both parental age groups and domains of well-being. compared to parents of children without such conditions, parents of children with developmental or mental health problems experience poorer psychological health, increased daily and global negative affect, and increased daily and global physical symptoms (ha et al., a; seltzer et al., ) . additionally, parents of children with developmental and mental health problems experience greater caregiving burden, such as more restrictions on their time (smith and grzywacz, ) and more negative parenting experiences (song et al., ) compared to parents of children without such conditions. for instance, parents of children with developmental conditions or mental health problems have reported a greater burden associated with caregiving (greenberg et al., ) , attributing more stress to their child with special needs than to other siblings (baxter et al., ) . furthermore, this type of caregiving has been associated with physiological dysregulation (barker et al., ; seltzer et al., ) , accelerated cognitive aging (song et al., ) , and being more vulnerable during periods of economic downturn (song et al., ) . in general, providing care for a child with these conditions can contribute to a feeling of chronic stress for parents (baxter et al., ; masefield et al., ) , which presents a particularly troubling problem, as children with such conditions are likely to reside in the home longer than their typically-developing peers (seltzer et al., ) . this study presents a longitudinal extension of a previous cross-section study of examining the potential age-attenuation of the stress of caring for a child with disabilities on the well-being of parental caregivers (ha et al. ) . ha and colleagues ( ) found that midlife j o u r n a l p r e -p r o o f longitudinal changes in well-being of parents parents of children with developmental or mental health problems had significantly higher negative affect and more somatic symptoms than a comparison sample of parents. furthermore, those with children with developmental conditions also had poorer psychological well-being than the comparison sample. additionally, among those with children with developmental or mental health problems, older parental age of onset of the child's condition was protective of parental well-being, and longer duration of the child's condition also predicted better health outcomes, suggesting that parents may adapt to the stress of their caregiving role over time. although these findings provide initial evidence of potential adaptation among parents, they are limited by cross-sectional designs. longitudinally, parents of individuals with developmental conditions have shown declines in some aspects of physical and psychological well-being into old age, with parents whose child still resided at home during adulthood at greatest risk (namkung et al., ) . therefore, there is still much to be learned about how the impact of caregiving stress changes over time, especially for parents of children with mental health problems, who may be less likely than individuals with developmental conditions to continue residing at home into adulthood. additionally, longitudinal data provides the opportunity to examine within-person change, which more accurately assesses whether parents truly adapt to this role over time. normative samples of adults generally evidence increases in well-being across adulthood. for example, older adults show reduced negative affect, greater well-being, and fewer negative emotional experiences compared to younger adults (carstensen and charles, ) . this trend has multiple explanations. for one, older adults, having lived longer, have access to a wider range of experiences and behavioral skills. therefore, older adults have more practice with j o u r n a l p r e -p r o o f longitudinal changes in well-being of parents interpreting social situations and regulating their emotions, as well as more varied exposure to such experiences (hess et al., ) . this improvement in emotion regulation helps explain general improvement in affective well-being (charles, ) . furthermore, socioemotional selectivity theory (carstensen et al., ) posits that because of a perceived decrease in the time remaining in life, older adults increasingly prioritize emotion-related goals, such as family and interpersonal relationships. not only do emotions themselves become more salient through the lifespan (carstensen et al., ) , but older adults also cognitively attend more to positive and less to negative emotional material, and negative experiences are more easily forgotten for older adults (charles, ) . the strengths and vulnerability integration model (i.e., charles, ) is based in socioemotional selectivity theory, but additionally posits that along with age-related strengths such as emotion regulation and salience of positive events, aging can also be accompanied by certain vulnerabilities that make dealing with emotional experiences more difficult. one such vulnerability occurs in the presence of chronic stress. when chronic stressors persist over long periods, negative experiences become unavoidable: despite advanced emotion regulation skills, adults may not have the option of reappraising or directing attention away from the source(s) of certain stressors. for example, empirical studies have found that compared to younger adults, older adults are less reactive to daily stress that was avoided, but equally reactive to stress when it does occur (charles et al., ) . in other words, unavoidable stressors present a meaningful threat to well-being, even for older adults. over time, persistent exposure to unavoidable stressors may reduce the actual capacity for emotion regulation (charles, ) . that is, chronic stress may work to cancel out the normative age-related benefits of emotion regulation. j o u r n a l p r e -p r o o f longitudinal changes in well-being of parents as a chronic stressor, caring for a child with developmental or mental health problems may alter trajectories of age-related patterns in well-being for this subset of parents. for example, the finding that older parental age at onset of the child's disorder is associated with better health (ha et al., ) , suggests that older parents have built up emotional resources throughout the lifespan that can help alleviate the stress associated with caregiving. however, little is known about how patterns of chronic stress may change as children themselves grow older and become less likely to live at home. in general, interactions between parents and their adult children get more positive with time, and parent-child dyads tend to engage in behaviors that maximize positive feelings in the tie and minimize dissent as children age (birditt et al., ). however, this may be less true of parent-child dyads characterized by stressful relationships, such as when the adult child has a disability or other chronic condition. for instance, parents report more negative than positive interactions with children experiencing various physical and emotional problems (birditt et al., ) , which have been shown to negatively impact physiological stress responses (birditt et al., ; seltzer et al., ). utilizing longitudinal data will allow us to evaluate whether these negative patterns persist or attenuate over time for parents whose adult child has developmental or mental health conditions. the stress associated with parenting a child with developmental or mental health problems affects parents differentially depending on both personal characteristics of the parent and those associated with the diagnosis itself. for instance, previous work has suggested that mothers are particularly vulnerable to the impacts of parenting a child with such problems, in terms of both subjective well-being and physical health (see pinquart and sörensen for meta-analysis) . for instance, mothers' economic situations may be more heavily impacted by j o u r n a l p r e -p r o o f longitudinal changes in well-being of parents caregiving burden than that of fathers, resulting in lower earnings and less time spent working (parish et al., ; seltzer et al., ) . additionally, they may be at risk for more physical symptoms associated with caregiving burden than fathers (namkung et al., ) , as well as poorer mental health outcomes (homan et al., ; penning and wu, ; smith and grzywacz, ) , and cognitive functioning (song et al., ) . however, other work has suggested that gender does not moderate the effects of parental caregiving stress (ha et al., ) , and that mothers potentially benefit more from the positive aspects of caregiving compared to fathers (homan et al., ) . therefore, further investigation into gender differences in caregiving stress is needed. additionally, parents of children with developmental conditions display different patterns of well-being than parents of children with mental health problems (greenberg et al., ; ha et al., a; seltzer et al., ) . for example, parents of individuals with mental health problems may face more unpredictability in daily experiences with their child, whereas parents of individuals with developmental conditions tend to adapt family routines more sustainably, especially given the typically younger age of onset of these conditions (seltzer et al., ) . furthermore, parents of children with mental health problems may be at greater risk for financial problems such as unexpected costs and barriers to services (song et al., ) . therefore, one must consider each group individually, asking whether parents of children with developmental and mental health problems adapt such that they reach more normative levels of well-being in older adulthood, or if this type of parenting presents as a chronic stressor with lasting impact over the lifespan. the current study used data from a representative sample of midlife-to-older adults who have at least one child with a developmental condition or mental health problem and from a comparison group of parents to better understand how health and well-being change throughout the lifespan. some models implemented in the current study were previously tested by ha and colleagues ( ) using cross-sectional data that were collected between and . the current study extended these analyses by incorporating a second wave of data from the same respondents, collected approximately years after the previous wave. based on the crosssectional findings from this sample (i.e., ha et al., ) and theoretical propositions, our hypotheses are: . having a child with a developmental or mental health problem will predict higher negative affect, lower psychological well-being, and a greater number of somatic symptoms, at both a baseline time point and a -year follow-up, compared to parents of children without these problems. having a child with a developmental condition or mental health problem will be associated with net increases in negative affect, decreases in psychological well-being, and increases in somatic symptoms from the first time point to the second. a. parental age will moderate these effects such that older parents of children with developmental or mental health problems will not show elevated negative affect. b. parental gender will moderate these effects such that mothers will experience greater detrimental effects on well-being compared to fathers. . within groups, longer duration of the child's condition and older parental age will be related to better parental well-being for parents of children with developmental or mental health problems. at the first time point, respondents were identified as having a child with any developmental, mental health, or other diagnosis; of these had only children with other conditions such as injuries, health problems like diabetes and heart conditions, or vision / hearing impairments, that were not included in this study. of the remaining respondents, had completed the data necessary for inclusion. inclusion was contingent upon having participated in both a structured phone interview and a battery of questionnaires, which included the questions used in the following analyses. the comparison sample was drawn from respondents who reported having at least one child, but who did not have any children with a developmental or mental health diagnosis, or other chronic condition. additionally, this group must not have provided care for more than one month to a family member or friend who, "because of a longterm, physical or mental condition, illness, or disability was not able to take care of him-or herself." these criteria left a sample of , participants in the comparison sample. of , eligible participants ( parents of individuals with disabilities or mental health problems and , comparison respondents), , participated in midus iii. of these, . % (n = ) were excluded from the present analyses because they completed the telephone interview but did not return the self-administered questionnaire mailer, which contained the outcome variables of interest for this study. additionally, some parents in the comparison sample no longer met the inclusion criteria at midus iii. a group of parents had a child diagnosed with a developmental condition or mental health problem between midus ii and iii. furthermore, parents had reported caregiving responsibilities between midus ii and iii that would preclude them from being in the comparison sample; of these were those who also had a child with a new diagnosis; thus, respondents were dropped to retain a true comparison sample. therefore, the total sample consisted of parents of children with developmental conditions, parents of children with mental health problems, and comparison parents (n = , ). attrition due to death accounted for . % of all attrition ( respondents from the samples of parents of children with developmental or mental health problems and from the comparison group). compared to the longitudinal sample, those who completed midus ii but did not complete midus iii (including the deceased) had a lower income and education level, were less likely to be employed, and were less likely to be married. considering those who survived until midus iii (i.e., those who could have participated but did not), those who remained in the longitudinal sample were older by . years. respondents with children with developmental or mental health problems were no more likely to drop out than those in the comparison sample. attrition was higher for parents of children with developmental conditions ( . %) versus those with children with mental health problems ( . %). table gives the j o u r n a l p r e -p r o o f breakdown of conditions and age of onset for the conditions included in the analytic sample, which is comparable in proportions to the sample analyzed in ha and colleagues' ( ) analysis of the sample. [ table here] negative affect. the scale for negative affect (mroczek & kolarz, ; α time = . , α time = . ) consisted of six items that assessed how often in the past days the respondent felt: so sad nothing could cheer you up, nervous, restless or fidgety, hopeless, that everything was an effort, and worthless. responses were on a likert-type scale from (all of the time) to (none of the time) and were reverse coded so that higher responses indicated more negative affect. the total negative affect score was the sum of these six items. this sum was calculated when at least half ( or more) of the items had been completed and when this was true, individual mean imputation was used. psychological well-being. the measure for psychological well-being was the sum of six domains of well-being: autonomy, environmental mastery, purpose in life, positive relations with others, personal growth, and self-acceptance (ryff, ) . each domain is assessed on seven items, for a total of items (α = . at times and ). responses were on a likert-type scale from (strongly disagree) to (strongly agree). items were coded so that higher scores indicate greater psychological well-being. as with the measure of negative affect, mean imputation was used for those who had scores on more than half (four or more) of the items for each domain, and sums were calculated. somatic symptoms. the measure of somatic symptoms (α time = . , α time = . ) was a count of up to seven physical symptoms: headaches, backaches, sweating a lot, aches / joint j o u r n a l p r e -p r o o f stiffness, trouble falling or staying asleep, leaking urine, or aches / pain in extremities. these particular symptoms were chosen in order to maintain consistency from ha and colleagues ( ) analyses of this sample. respondents reported how often they had experienced these symptoms in the last days, from (not at all) to (almost every day). the cutoff score was (several times a month) or greater for a symptom to be counted. parenting type. parenting type was coded as a categorical variable, based on whether the respondent was a parent of a child with a developmental condition (coded ), mental health problem (coded ), or a child without these diagnoses (coded ). some respondents (n = ) qualified for both parenting type categories, as they had either one child who would fit into both the developmental and mental health problem categories, or one child in each category. these respondents were categorized into either the developmental or mental health groups based on criteria determined by ha and colleagues ( ) in their previous examination of this sample. these were ( ) which condition was more chronic, and ( ) which had the longer duration. therefore, if the child had both a chronic developmental condition and a chronic mental illness, the decision was that they should be placed in the developmental condition group as these problems begin earlier in life than mental health diagnoses. this resulted in four respondents being placed in the developmental conditions group, and nine in the mental health problems group. responses from time were used to measure all sociodemographic variables, to capture respondents' current situation. age and sex were included as predictors in this study. age was measured in years, based on the respondent's birthdate. sex was assessed with one item during the telephone interview, with response options, "male," "female," and "don't know." sex was measured at time point . the following were also j o u r n a l p r e -p r o o f included as control variables: race ( =non-hispanic white, = others), education (in years), income, employment status ( = working for pay, = not working for pay), marital status ( = married, = unmarried), number of children, and number of co-resident children. to address between-group differences in the outcome variables of interest (hypothesis ), analyses of variance (anovas) were used with parenting group (developmental condition, mental health problem, or comparison group) as the grouping factor. post-hoc tests for individual group differences used dunnett's t t-tests, which account for unequal variances across groups. power analyses based on the smallest sample size (n = for the mental health parent group) suggested that these anovas had sufficient power to detect small-to-medium effect sizes (cohen's f of . or greater). to measure change from time to time (hypothesis ), we used hierarchical linear regressions with time one levels as predictors of time two outcomes to examine the effects of parental group, age, and sex on change in the outcome variables, as well as their interaction effects, while controlling for potentially confounding variables. due to different patterns of missingness across the outcome variables of interest, we conducted a sensitivity analysis running the models with only those with complete data for all outcome variables (n = , ). the pattern of results remained the same for this sample, therefore we decided to use the models with the most possible data. power analyses suggested that the full models were well-powered to detect even small effect sizes (based on a cohen's f of . ; cohen, ) . specifically, the model for negative affect had a power of . , the model for psychological well-being had a power of . , and the model for somatic symptom had a power of . to detect a small effect size. finally, we used multiple linear regressions to examine within-group effects of conditionrelated variables on the well-being of parents of individuals with developmental and mental health problems separately at time two (hypothesis ). due to the smaller sample sizes, these models were sufficiently powered to detect medium effect sizes (cohen's f of . or greater) but not smaller. the models for the developmental conditions parent group had sufficient power (above %) to detect effect sizes of cohen's f of . or greater, while the models for the mental health parent group had sufficient power to detect effect sizes of cohen's f of . or greater. for within-group comparisons of these outcomes at time one, see ha et al., . table . ). dunnett's t tests were used to probe these interactions, to account for unequal variances between the three groups. specifically, parents of children with mental health problems were older than those in the comparison group (p < . ) and developmental disabilities parent group (p = . ). they were also less likely to be employed than those in both the comparison (p < . ) and developmental disabilities parent group (p < . ), and less likely to be married than those in the comparison group (p = . ). those with children with developmental conditions had more children than the comparison group (p = . ) and more children who resided at home percentage of female respondents (i.e., mothers) was lower in the comparison group than in both samples of parents whose children had disabilities (p = . compared to parents of individuals with developmental disabilities, p < . compared to parents of individuals with mental health problems). among the groups of parents with children with developmental or mental health problems, there were group differences in condition-related variables. specifically, the duration of the condition was longer among those with children with developmental disabilities compared to parents of children with mental health problems (t ( ) = . , p < . ). additionally, their children were older (t ( ) = - . , p < . ), and less likely to be female than those in the mental health group (t ( ) = - . , p = . ). table presents group by timepoint anovas as well as the results of post-hoc dunnett's t tests probing specific between-group differences, which test hypothesis . there was an omnibus effect of time on increased somatic symptoms across the three groups (f ( , ) = . p = . ), as well as a downward trend in negative affect over time (f ( , ) = . , p = . ). of interest, there were also omnibus effects of parenting group on negative affect (f ( , ) = . , p < . ), psychological well-being (f ( , ) = . , p < . ), and somatic symptoms (f ( , ) = . p < . ) across timepoints. specifically, at time , our results repeated the previous crosssectional analyses conducted by ha and colleagues ( ) , with parents of individuals with developmental conditions having higher negative affect (p < . ), poorer psychological wellbeing (p = . ), and more somatic symptoms (p < . ) compared to a comparison sample of parents. additionally, parents of individuals with mental health problems had higher negative affect (p = . ) and more somatic symptoms (p = . ) than comparison parents at time , which was also consistent with the previous analysis of a similar sample (ha et al., ) . this is in line with hypothesis . there was not evidence for group by time interaction effects for any of the three outcomes, indicating that group differences present at time largely persisted at time , but failing to support the specific trajectories predicted in hypothesis . at time , parents with children with developmental conditions had higher negative affect (p < . ), lower psychological well-being (p = . ), and more somatic symptoms than those in the comparison group (p = . ), supporting hypothesis . in contrast, parents of children with mental health problems had higher negative affect that the comparison group (p = . ), but did not differ in terms of psychological well-being (p = . ) or somatic symptoms (p = . ), partially supporting hypothesis . parents of children with developmental conditions and mental health problems did not differ from each other on any of the measured outcomes. mean levels of each outcome variable at each timepoint are displayed in figure . [ table here] [ figure here] table displays results of hierarchical regressions assessing longitudinal change in parental well-being, which tested hypothesis a and b. model includes only parenting group and demographic variables, model includes moderating effects of age by parenting group, and model includes moderating effects of sex by parenting group. all models control for time outcomes. in model , there was a significant main effect of having a child with either a developmental condition (β = . , t ( ) = . , p = . ) or mental health problem (β = . , t ( ) = . , p = . ) in predicting elevated negative affect. these results partially support hypothesis . older age was associated with declining psychological well-being (β = - . , t ( ) j o u r n a l p r e -p r o o f = - . , p = . ), but not the other two outcomes. additionally, being female was predictive of increases in psychological well-being (β = . , t ( ) = . , p = . ). [ table here] age and sex moderations were partially supported for parents' negative affect. a significant age by condition interaction was found for the effect of parenting a child with a developmental condition on negative affect (β = - . , t ( ) = - . , p = . ). a simple slopes test was used to probe this interaction, which revealed that the effect of parenting a child with developmental conditions on negative affect was only observed for younger parents (- sd; β = . , t ( ) = . , p = . ) but not older parents (+ sd; β = . , t ( ) = . , p = . ). the region of significance test showed that the slope was significant and positive for those under . years old. this effect was not significant for parents of individuals with mental health problems. in other words, these results provide some support for age attenuation of the effect of caring for a child with a developmental disability on negative affect. this interaction is consistent with hypothesis a, and is reflected in figure . age did not moderate the effect of parenting a child with a developmental disability or mental health problem on parents' psychological well-being or somatic symptoms. additionally, a gender by condition interaction was found at the trend level such that the effect of caring for a child with a mental health problem had a greater impact on the negative affect for fathers than for mothers (β = - . , p = . ). a simple slopes test confirmed that the effect of having a child with a mental health condition was associated with increased negative affect for fathers (β = . , t ( ) = . , p = . ) but not for mothers (β = . , t ( ) = . , p = . ). this is depicted in figure three condition-related factors that may be related to well-being were examined: duration of the child's condition, having multiple children with disabilities or mental health problems, and whether or not the target child co-resided with the parent at time . a summary of results appears in table . [ table here] among parents of individuals with developmental conditions, mothers had a higher number of somatic symptoms than fathers (β = . , t = . , p = . ). additionally, a trendlevel effect emerged suggesting that having a child who remained in the parental household was associated with poorer psychological well-being for parents of individuals with developmental conditions (β = - . , t = - . , p = . ). among those with children with mental health problems, longer duration of the child's condition was associated with elevated negative affect (β = . , t = . , p = . ), whereas parent's current age was associated with lower levels of negative affect (β = - . , t = - . , p = . ). these results provide mixed support for hypothesis . the results of this longitudinal study paint a bittersweet picture for the change in the well-being of parents of individuals with developmental and mental health problems, similar to evidence suggested by previous longitudinal work (e.g., baxter, cummins, & yiolitis, ; namkung et al., ) . parents in both of these groups showed normative decreases in negative affect over time that were in line with those experienced by the sample as a whole (see table for time effects). this was especially true for older parents. however, the experience of normative age-related changes in well-being also suggests that group differences present at earlier timepoints persisted into later life. for instance, average levels of negative affect were higher among both parents of children with developmental problems and mental health conditions compared to parents of non-disabled children, even into late life, which provided support for hypothesis . interaction probes revealed that the significance was driven by the younger age group, who showed a blunted decrease in negative affect over time compared to older parents (see figure ), which supports hypothesis a. although not statistically significant, younger parents (< years old) were more likely to still reside with their child with a developmental condition ( %) compared to older parents ( %) at the second wave of data collection. therefore, these parents may experience a more active caregiving role compared to older parents. parents of children with developmental conditions also retained poorer psychological well-being and physical symptoms compared to parents of children without these conditions. in contrast, parents of children with mental health problems no longer differed from the sample of comparison parents in terms of psychological well-being or somatic symptoms by the second time point (see table ). contrary to previous findings (e.g., herring et al., ; homan et al., ; parish et al., ; smith and grzywacz, ) and hypothesis b, a sex interaction j o u r n a l p r e -p r o o f showed that the negative affect of fathers was more vulnerable to impacts of caregiving stress than that of mothers (see figure ). it is possible that fathers have fewer sources of social support compared to mothers, and therefore have fewer buffers against the stress of these unique caregiving situations. examining the reasons why change in well-being may differ for aging fathers and mothers will be an important area of future study. within-group analyses of parents of children with developmental and mental health problems revealed potential differences in how time impacts the effect of caregiving burden (see table ). specifically, having a child with a developmental disability was particularly harmful for mothers' negative affect, and may impact negative affect levels more if the child still resides at home. these findings are consistent with gender differences discussed in other literature (namkung et al., ; penning and wu, ; pinquart and sörensen, ) , as well as the idea that parents whose child resides at home into adulthood may be particularly vulnerable to the effects of caregiving burden (namkung et al., ) . furthermore, for parents of individuals with mental health problems, a longer duration of the condition was associated with higher levels of parental negative affect. on the other hand, older current age was associated with lower levels of negative affect. this is consistent with the position of the strengths and vulnerability integration model (charles, ) , which emphasizes the potential for chronic stress to work against normative age-related improvements in well-being. however, also in line with socioemotional selectivity theory, older parents may be in a better position to combat this impact by utilizing more advanced emotion regulation strategies and other interpersonal resources. the intricacies of combining age-related increases in well-being with the chronicity of caregiving stress make results difficult to interpret, and may help to explain the relatively lower j o u r n a l p r e -p r o o f reliability of these findings. therefore, replication of these results with larger and more diverse samples will be critical in informing any future prevention or intervention efforts. regardless, it is noteworthy that condition-related factors are predictive of parental well-being longitudinally, when few parents were still co-residing with the target child (only % of target children coresided at time , compared with % at time ). perhaps the largest strength of this study is its longitudinal design, which allowed us to examine change in well-being over a span of approximately years. additionally, given the age of the sample, we were able to examine change in many factors that vary throughout the lifespan but are often captured only at one time point, such as the co-resident status of the child and the impact of the condition's duration on parental well-being, in addition to capturing multiple instances and measures of well-being itself. this revealed important nuances compared to previous cross-sectional work with this and similar samples. finally, the results are strengthened by the fact that the study utilized a nationally representative sample of parents whose participation was not motivated by or dependent on their child's condition, which is uncommon in other work related to non-normative parenting. despite the methodological strengths of this study, the results must be interpreted in light of its limitations. by combining parents into the broad categories of having children with developmental conditions, mental health problems, or neither of these problems, we lose some within-group variation that comes with the qualities of the diagnosis. for instance, masefield and colleagues ( ) notes that caring for children with multiple disabilities may pose the greatest risk to caregiver health, while individual disabilities may be differentially associated with specific health outcomes. certainly, differences in diagnostic categories affects the impact of caregiving stress, as well as how stress manifests in the daily lives of parents (i.e., consistent low-level stress versus more acute stress), as well as the long-term nature of the disability. although these nuances were beyond the scope of the current study, future work with larger samples and more power to detect such effects should consider within-group change among parents of children with more specific diagnoses. due to the long nature of the study, unmeasured factors likely play a role in influencing the physical and psychological health of these participants, which should be probed in future studies. finally, as with any study covering such a lengthy period, we were faced with non-random attrition and mortality issues that limited power to detect more specific effects. in general, the evidence for lifespan gains in well-being presented in this study provides support for socioemotional selectivity theory (carstensen et al., ) as a useful tool for modeling age-related change in populations as well as at the person level. additionally, this study provides opportunities to further examine the strengths and vulnerabilities hypothesis by suggesting that some age-related gains in psychological well-being are observed even in the face of chronic stressors such as caregiving stress, while others, such as changes in affect, may be undermined by this type of stress. furthermore, given the important group differences between types of caregivers (e.g., those for children with developmental conditions versus those with mental health problems), this study contributes to a body of research suggesting that specific elements of the caregiving experience may contribute to unique strengths and vulnerabilities in the face of chronic stress (e.g., ha et al., ; song et al., ) . additionally, the current study aligns with previous work that has identified vulnerabilities within groups of parents caring for children with developmental or mental health j o u r n a l p r e -p r o o f problems that may be uniquely exacerbated in times of acute stress, such as the current global covid- pandemic. for instance, parents of children with developmental and mental health problems can be more heavily impacted by downturns in the economy (song et al., ) , as well as being at risk for psychological, physiological, and cognitive dysregulations (ha et al., ; seltzer et al., ; song et al., ) . presumably, these adverse effects may be intensified during periods such as this one, when finances are more uncertain, time spent at home has increased, and access to resources may be very limited. therefore, prevention efforts aimed at improving the quality of life of families during periods of acute stress such as the current pandemic should pay special attention to the vulnerabilities of these groups of parents, including the vulnerabilities identified in the current study. overall, this study supports that parenting a child with developmental or mental health problems is a challenge that impacts the well-being of parents, even into their child's adult years and when fewer children reside in the home. however, these difficulties are nuanced by other within-person factors, such as age and sex, as well as factors related to the duration and time of a condition's diagnosis. future research should include contextual factors, such as social support, employment stress, and other relevant factors may influence how parents with high caregiving stress can cope. it is critical to identify malleable factors such as these, that could serve as intervention targets within this population. additionally, research particularly with older samples could consider the potential benefits and rewards of unique caregiving situations. for instance, older parents who are more attuned to positive emotionality and social experiences may also be more likely to experience positivity in their interactions with their adult children with disabilities or mental health conditions. overall, future work should attempt to probe how parents in these f-values reported here are within-timepoint; one-way anovas were conducted for all other variables; dunnett's t tests were used to probe specific effects and account for unequal variance between groups; two-tailed significance tests were used with an alpha level of . ; total degrees of freedom for f-tests ranged from , - , ; a indicates a significant mean difference between the comparison and developmental groups b indicates a significant difference between the comparison and mental health groups c indicates a significant difference between the developmental and mental health groups d indicates a difference between time and time scores across groups note. r = respondent; all coefficients reported are unstandardized; + = p < . ; * = p < . ; ** = p < . ; *** = p < . j o u r n a l p r e -p r o o f table . specific results of a group × time anova for each outcome are displayed in table . j o u r n a l p r e -p r o o f older parents experienced declines in negative affect over time, while younger parents did not experience this benefit. slopes that contributed to a significant interaction effect are denoted with an asterisk (*). simple slopes test revealed that there was a positive association between parenting a child with a developmental condition and negative affect for parents . years and younger. j o u r n a l p r e -p r o o f fig. . negative affect by parenting type and gender. fathers of individuals with mental health problems experienced increases in negative affect, while mothers did not. slopes that contributed to a significant interaction effect are denoted with an asterisk (*). simple slopes test revealed that the association between parenting a child with a mental health problem and negative affect was significant and positive for fathers but not mothers. j o u r n a l p r e -p r o o f daily stress and cortisol patterns in parents of adult children with a serious mental illness parental stress attributed to family members with and without disability: a longitudinal study daily interactions in the parent-adult child tie: links between children's problems and parents' diurnal cortisol rhythms if you can't say something nice, don't say anything at all": coping with interpersonal tensions in the parent-child relationship during adulthood emotion in the second half of life socioemotional selectivity theory and the regulation of emotion in the second half of life strength and vulnerability integration: a model of emotional well-being across adulthood now you see it, now you don't: age differences in affective reactivity to social tensions the differential effects of social support on the psychological well-being of aging mothers of adults with mental illness or mental retardation age and gender differences in the well-being of midlife and aging parents with children with mental health or developmental problems: report of a national study behaviour and emotional problems in toddlers with pervasive developmental disorders and developmental delay: associations with parental mental health and family functioning age and experience influences on the 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with a mental health problem or a developmental disability cognitive aging in parents of children with disabilities key: cord- - f azbjn authors: chaplin, lucia; ng, lauren; katona, cornelius title: refugee mental health research: challenges and policy implications date: - - journal: bjpsych open doi: . /bjo. . sha: doc_id: cord_uid: f azbjn mental illness is common among forced migrant populations, and ongoing mental illness can hinder refugees’ ability to negotiate the asylum process. this editorial rehearses the challenges of undertaking research among forced migrant populations, exploring how they could be addressed in future research, and outlines differences between forced migrant groups. it points to the growing body of evidence that can be called on in advocating for systemic change in government policy and mental health services, with significant support for a sensitive and objective inquisitorial approach to gathering evidence in support of asylum claims. the world currently hosts the highest number of refugees since the second world war. with nearly million forcibly displaced, million of whom hold refugee status, the needs of refugees and asylum seekers have become an increasing concern for mental health services. although the experience of each refugee and asylum seeker will differ, traumatic events and ongoing stress are often prominent. as a result, research into the mental health of refugees and asylum seekers has expanded. henkelmann et al have made an important contribution to this research by providing an up-to-date overview of the prevalence of mental illness among forced migrants. their intention was, in part, to highlight some of the heterogeneities among studies conducted in this arena, in addition to addressing the challenges faced in researching this population. their work indicates that mental illness is common among forced migrant populations and adds to the body of evidence that can be called on in advocating for systemic change in government policy and mental health services. there are many complexities in carrying out cross-culturally informed research with forced migrants. personal narratives, vulnerabilities, barriers to access and cultural perspectives on mental illness have been recognised as some of the difficulties in this field of research, particularly among refugees and asylum seekers. there is a pervasive 'culture of disbelief' in western asylum systems, whereby those claiming asylum are required to 'prove' their eligibility for legal protection. in the absence of personal documents (which are frequently left behind or lost during flight), asylum claims commonly rely on personal accounts. these claims are often heavily interrogated and scrutinised for any inconsistencies. as a result, the sharing of a story becomes a means through which safety is guaranteed or rejected. it is difficult for immigration officials, lawyers and clinicians carrying out their assessments to ensure that consent is fully informed and free from coercion. we have recently reported on the 'narrative dilemmas' asylum seekers often face in the process of recounting the experiences that led them to leave their countries of origin as well as during their asylum journeys. during the process of seeking refugee status, the expression of vulnerability can take on different meanings. asylum seekers may need medical certification, providing detailed accounts of their physical and psychological symptoms, to 'verify' their claim of torture. however, ongoing mental illness may hinder their ability to recount their trauma because such disclosures can be re-traumatising. this may have an adverse impact on their asylum claim as well as leading to underreporting of mental health problems in research studies. it has also been argued that western classifications of mental illness have an inappropriately ethnocentric focus. as responses to trauma vary across cultural and ethnic backgrounds, it can be difficult to interpret manifestations of mental illness universally owing to the lack of a nomenclature for trauma that is valid across cultures. thus, tools used for identifying groups who need specialist mental health attention may not be adequate among those from different cultural groups. this can make it difficult for clinicians to identify and diagnose those who may need specialist treatment and to make acceptable and effective care plans. henkelmann et al were unable to break down the available data by migration status, and instead used a broad and non-legal definition of 'refugee'. it may be argued that anyone who flees a country needs refuge and is therefore a 'refugee'. assigning a legal label is therefore a political process and may be of little relevance in the context of mental illness. however, we would argue that data relating to migration status are vital in future research in this area, as they allow us to investigate the specific mental health impacts of asylum policies. in this section, we will expand on some of the crucial differences between forced migrant groups. in international law, a refugee is defined as a person who: 'owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country'. this remains a narrow legal definition, which excludes categories of people who have been displaced outside of these boundaries, for instance those fleeing natural disasters. nevertheless, it confers a certain set of rights on the individual, including the right to live and work in the host country and subsequently to apply for permanent residence (in the uk, indefinite leave to remain (ilr)) or citizenship. for those fleeing generalised conflict or indiscriminate violence, a similar status of 'humanitarian protection' may be given. these statuses are both time-limited, and it is only when individuals are granted permanent residence/ilr or citizenship that their uncertainty over whether they will be forced to return to their country of origin can end. this may contribute to the findings of henkelmann et al that length of stay appeared to be unrelated to prevalence of mental illness. as the authors note, the findings may be different if broken down by whether permanent status was granted. an asylum seeker is anyone who has arrived in a host country and made an asylum claim. in the uk, while their case is being reviewed, they have the right to remain and are provided with a basic level of housing and subsistence, but (with very few exceptions) are not allowed to work. this existence 'in limbo', with the constant threat of imminent return, can represent a significant trauma in addition to their experiences in their country of origin and may increase their vulnerability to mental illness and impede recovery. traumatic journeys and post-migration factors less than % of refugees arrive in their host country through a resettlement programme in which they are given refugee status prior to arrival. these more favourable circumstances allow refugees to benefit from a greater degree of stability and certainty regarding their immigration status, along with the right to work or to claim mainstream benefits immediately. however, owing to the highly restricted availability of this route, many asylum seekers and refugees make long and risky journeys, and may arrive in their host country after having been exposed to additional trauma, such as trafficking or destitution, during their journey. this may leave them more vulnerable to a traumatic asylum process. henkelmann et al's study rightly makes reference to some of the post-migration factors that can affect mental health, including migration status, socioeconomic position, long-drawn asylum procedures, unemployment and discrimination. these factors may also contribute to a range of mental health problems, including significantly higher rates of psychosis, a diagnostic group that was not included in the authors' analysis. another diagnosis whose prevalence the study did not examine is 'complex post-traumatic stress disorder' (complex ptsd). this diagnostic concept, which is characterised by 'disorders of selforganisation' (impaired relationships, emotional dysregulation and negative self-concept) as well as core ptsd symptoms, has now been incorporated into icd- . complex ptsd is often found in the aftermath of multiple and repeated trauma such as the torture, modern slavery, human trafficking and sexual abuse experienced by many asylum seekers. the restrictive asylum systems in operation in most western countries mean that, in addition to threat of return, asylum seekers have no right to work, and live in poor housing with minimal monetary funds for subsistence. many are placed in immigration detention, a process likely to have an adverse impact on their mental health. furthermore, despite social networks being recognised as key sources of support for asylum seekers, dispersal policies in the uk have made it increasingly difficult for asylum seekers and refugees to integrate into a community, in addition to making clinical and research follow-up more challenging. many forced migrants remain undocumented and therefore largely invisible to healthcare and other support services. despite legal entitlement to primary healthcare services, many asylum seekers struggle to register with general practitioners owing to a lack of a fixed address, leading to substandard management of long-term health conditions. the covid- pandemic has also served to highlight the precariousness of their situation, given the current need for testing and tracing as part of a public health response. within the organisation for economic cooperation and development (oecd), canada has an explicitly inquisitorial asylum system. in europe, a lack of common standards in asylum policies has led to varied treatment between countries, many of which are adversarial and unwelcoming in their approach to refugees and asylum seekers. however, one example to be commended is germany's response to the large influx of syrian refugees to europe in , wherein the government decided to accept a comparatively high number of asylum seekers as part of an organised resettlement programme for syrians fleeing conflict. according to statistics published by the world bank, in germany remained the european country with the highest number of refugees ( . million, compared with the next highest country, france, with ), with the uk hosting roughly refugees. henkelmann et al have collated clear and compelling evidence of the high rate of mental illness among forced migrants. their research has also highlighted that undertaking research among forced migrant populations can be challenging. such research deserves prioritisation. mental illness itself may be a factor impeding recognition of the need for and entitlement to protection. in countries where an adversarial asylum policy is in place, in which asylum seekers are required to prove their entitlement against the host country's attempt to disprove it, the presence of a mental health condition will likely amplify the unfairness of an already hostile system and risk their ability to gain refugee status. henkelmann et al's study therefore provides significant support for the contention that, as we have previously argued, a fair asylum policy for vulnerable people, utilising an inquisitorial approach where evidence can be gathered in a sensitive and objective manner, is crucial for a fair asylum process. all authors were involved in developing the concept and planning. l.c. drafted the majority of the manuscript, with some sections drafted by l.n. l.n. and c.k. completed edits, and all authors reviewed and approved the final version of the manuscript. declaration of interest c.k. reports receiving a salary from the helen bamber foundation outside the submitted work. icmje forms are in the supplementary material, available online at https://doi.org/ . /bjo. . . html#:∼:text=at% least% . % million% people,under% the % age% of% anxiety, depression and post-traumatic stress disorder in refugees resettling in high-income countries: systematic review and meta-analysis beyond belief: how the home office fails survivors of torture at the asylum interview. freedom from torture the dual imperative in refugee research: some methodological and ethical considerations in social science research on forced migration the texture of narrative dilemmas: qualitative study in front-line professionals working with asylum seekers in the uk. bjpsych bull culture-sensitive psychotraumatology refugee trauma: culturally responsive counseling interventions united nations general assembly. convention relating to the status of refugees non-affective psychosis in refugees lift the ban: why people seeking asylum should have the right to work refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of . million people in sweden the international trauma questionnaire: development of a self-report measure of icd- ptsd and complex ptsd a developmental approach to complex ptsd: childhood and adult cumulative trauma as predictors of symptom complexity the impact of immigration detention on mental health: a systematic review immigration and refugee board refugee population by country or territory of asylum key: cord- -ml qjipn authors: kopelovich, sarah l.; monroe-devita, maria; buck, benjamin e.; brenner, carolyn; moser, lorna; jarskog, l. fredrik; harker, steve; chwastiak, lydia a. title: community mental health care delivery during the covid- pandemic: practical strategies for improving care for people with serious mental illness date: - - journal: community ment health j doi: . /s - - -z sha: doc_id: cord_uid: ml qjipn the covid- pandemic has presented a formidable challenge to care continuity for community mental health clients with serious mental illness and for providers who have had to quickly pivot the modes of delivering critical services. despite these challenges, many of the changes implemented during the pandemic can and should be maintained. these include offering a spectrum of options for remote and in-person care, greater integration of behavioral and physical healthcare, prevention of viral exposure, increased collaborative decision-making related to long-acting injectable and clozapine use, modifying safety plans and psychiatric advance directives to include new technologies and broader support systems, leveraging natural supports, and integration of digital health interventions. this paper represents the authors’ collaborative attempt to both reflect the changes to clinical practice we have observed in cmhcs across the us during this pandemic and to suggest how these changes can align with best practices identified in the empirical literature. the current coronavirus disease (covid- ) pandemic has required dramatic transformation of the delivery of outpatient mental health services for individuals with serious mental illness (smi) in the us. federal and state guidelines limit face-to-face contact and specifically request that health facilities limit in-person contact. this transformation in care delivery has tremendous public health implications, as individuals who receive care through the public mental health system are particularly vulnerable during public health crises (druss ) . multiple factors contribute to increased risk of infection and poorer outcomes in this population, including disparities in access to healthcare, and increased risk of contracting covid- due to social inequalities (e.g., increased rates of poverty leading to residential instability and food security, high unemployment rates), higher rates of medical conditions, and unhealthy behaviors (e.g., chowkwanyun and reed ) . moreover, the risk of poorer mental health outcomes is further exacerbated by the pandemic, and this must also be recognized as a public health priority (williams and cooper ) . since there is currently no vaccine or specific treatment for covid- , current health efforts focus on providing prevention and screening, ensuring access to appropriately intensive services for those with the most severe symptoms, and maintaining continuity of treatment for other chronic conditions (adalja et al. ) . the pandemic presents a serious threat to the continuity of treatment for smi. it is critical for community mental health centers (cmhcs) to develop plans to ensure that they can maintain essential services and adequate supplies of psychotropic medications. this paper aims to provide community mental health providers who are working with clients with smi with practical recommendations for optimizing the continuity of care in the context of rapidly evolving mandates and recommendations for healthcare providers. clients with smi who are served by cmhc outpatient and outreach teams may have chronically elevated risk of severe functional impairments, emergency department visits, psychiatric hospitalizations, harm behaviors, arrest and incarceration, food and water insecurity, and homelessness. during a public health crisis, these risk factors must be considered along with the individual's risk of covid- infection to determine how to best meet an individual's treatment needs. medical and psychiatric risks and benefits for every individual client should be weighed by the clinical team, with input from the medical director as needed, to decide if there is an urgent or essential need that necessitates inperson care and, if so, what modifications to care delivery are necessary. in addition, natural supports, warm lines, and pandemic-compatible psychiatric advance directives should become the standard of care in the peri-and post-covid era. clinics should consider a spectrum of service delivery options that are responsive to clients' needs and preferences for care as well as their psychiatric and medical risk status (see fig. ). these care delivery options are not mutually exclusive. indeed, using a variety of care delivery methods in combination may support frequent contact without increasing the risk of client or staff exposure to the virus. the spectrum includes in-person care in the community with appropriate preventative measures; clinic-based care in a larger room that allows physical distancing; clinic-based telehealth, in which the client is accommodated in a private clinic office for a telepsychiatry session with their provider; clinic-based care in a standard office in a manner consistent with local public health guidelines; and telehealth encounters with clients at home or in the community. clinic-delivered care can also be extended by coaching family members, establishing linkages to warm lines, and supplemental forms of e-mental health (for a review of e-mental health literature, see lal and adair ) . each of these options are reviewed below, followed by delineation of key considerations for care delivered in-person and by telehealth. while most cmhcs may be able to shift to telehealth practices for many clients, a significant group of clients will continue to need in-person services to help meet basic needs or because they lack access to the required technology or data plans required to engage in telehealth. but telehealth can be adapted to address technologic or psychosocial barriers. for instance, the client can present to clinic for a telehealth session in a private office, thereby minimizing close contact with clinic staff. clients who present with cognitive disorganization or paranoia related to technology or surveillance may be amenable to telephone encounters, which represent an efficient, familiar alternative for clients, and hold greater pragmatic appeal to cmhcs in states that can now receive equitable compensation for certain types of telephone encounters (e.g., washington state emergency order no. - , ) . telephone encounters have limitations that impact clinical care, though, as they may limit clinical observation, therapeutic engagement, assessment, and interventions, further reinforcing the need to diversify therapeutic contacts. in the short term during the pandemic, providers may need to temporarily shift from skills teaching and other rehabilitation efforts to direct assistance with basic needs. to this end, providers may need to coordinate with the client, natural supports, representative payees, faith communities, and social service organizations to locate resources, prepare care packages, and even prepare and drop off warm meals. providers doing outreach visits should avoid entering homes, especially if it is a closed space or when others are in the residence and control over physical distancing is less certain. outreach teams should meet outside the residence in well-ventilated areas, to visually assess how the person is doing, present as a familiar and comforting supportive social visit, model and reinforce behaviors, deliver medications, and provide an in-person demonstration of how to use smartphones or other devices to engage in e-mental health. with all in-person encounters, providers need to be familiar with and adhere to local public health infection control guidelines on personal protective equipment (ppe) and physical distancing. in addition to a multimodal plan service delivery, care should also leverage all available members of the clinic staff, natural supports, and ancillary services, in an "all hands on deck" fashion. administrative staff such as receptionists can make welfare phone calls to check on clients, or may be able to provide learning sessions to clients to prepare them for telehealth sessions. peer specialists can continue to play a key role in supporting person-centered wellness management and coping skills, coaching and consultation to promote self-efficacy and self-advocacy, and problemsolving client needs. peer specialists and case managers may be helpful in facilitating access to virtual spiritual, peerbased, recreational, and other communities to help clients connect with others. therapists may replace or augment full clinical sessions in the short-term with telephone sessions intended to coach the client in the acquisition, strengthening, and rehearsal of specific behavioral skills in order to avert a behavioral crisis. families and caregivers may be in a position to support their loved one experiencing a mental illness, and are available more hours in a given day or week than the treatment team, especially if living with their loved one. now, more than ever, providers need to enlist families as partners in care delivery. providers can augment services by directing some of their efforts to natural supports, such as, skills they teach directly to individual clients. as a team, providers can work with both clients and families to plan for structuring their day, especially with leisure activities and opportunities for social connectedness while physical distancing. while this places demands on families, it may prove to be an important avenue for supplementing shorter clinical sessions, particularly with clients who are not engaging in video or phone sessions. families can be further supported with cloud-based shared folders or other resources that contain educational and training materials (e.g., manuals, clinical tips sheets for family members) to supplement direct care. additionally, many community mental health systems offer support from trained family specialists who have lived experiences with a loved one with mental illness who may be available to families during this time. for those who are not connected to family or other natural supports, providers will need to help identify and extend other natural supports available to the client. as long as physical distancing is necessary, virtual connections and online communities are even more key. unlike hotlines or crisis lines, which are designed to be responsive to individuals in the throes of a psychiatric emergency, warm lines are designed to be a comforting option for people experiencing distress and seeking emotional support. the covid- pandemic has led to the expansion of the availability of warm lines, many hosted by peer support organizations. a national crisis text service, crisis text line, provides free confidential text message service for people in crisis (users can text home to to be connected to a crisis counselor). some states have developed their own emotional support text lines, such as call calm, a free-of-charge texting service made available by the illinois department of human services' mental health division to english and spanish-speaking residents (halstead ) . providers may wish to curate these resources, help input phone numbers into clients' cell phones, and post them to agency websites or social media. providers should work with clients to update safety plans, and help clients to establish or update a psychiatric advance directive that includes contingency planning related to pandemics. advance directives delineate an individual's wishes in the event that they are unable to express their wishes for health care and treatments. under federal law, facilities receiving cms reimbursements are required to use advance directives, including for behavioral health conditions. the american psychiatric association's smi adviser program (www.smiad viser .org) has released a digital version of a psychiatric advance directive, called my mental health crisis plan (smi advisor ) that meets the legal requirement for all states and allows for tailoring to where the individual resides. companion guidance documents to facilitate collaboration with both natural supports and providers to develop and execute the psychiatric advance directive are in development. as hospitals and crisis centers may be differentially impacted by the covid- pandemic, individuals should factor in treatment setting to their advance directives. it is important to inform the client that it may not be possible to accommodate some aspects of their advance directive, given that circumstances and resources are quite fluid during this time. providers should help to problem-solve around these contingencies in order to best ensure maximal application of the individual's wishes within their psychiatric advance directive. the virtues of virtual care have been well-documented, as has its underutilization in public behavioral health (schmeida et al. ; simmons et al. ) . institutional and policy barriers to broad dissemination of telepsychiatry and digital health interventions (saeed et al. ) are now being surmounted in response to emergent need. federal policy shifts have also signaled widespread recognition that the flexible use of digital health technologies may be required to maintain uninterrupted mental health services during the covid- crisis. for instance, the office for civil rights (ocr) has announced that it would waive penalties embedded in the health insurance portability and accountability act (hipaa) against health care providers who serve their clients using "everyday communications technologies," (department of health and human services ) although we are sensitive to the dialectic between reducing barriers to care and protecting patient rights (hall and mcgraw ) . evidence suggests that the use of telepsychiatry (both via telephone and videoconferencing) is both feasible and acceptable for individuals with smi, and may improve client outcomes (baker et al. ; kasckow et al. ) . that said, research on telepsychiatry practice has typically involved rigorous implementation planning, support, and evaluation. in contrast, the urgent need to provide telehealth services quickly has resulted in clinical sites across the us scrambling to adopt new technology, workflows, job aids, and training for their providers who are simultaneously addressing emergent clinical needs. clients may not have access to the hardware, software, or data plans required for telepsychiatry. both staff and service users may require several learning sessions to become proficient enough for independent use. key targets for assessment and management using telehealth modalities are discussed in the next section. telepsychiatry practice guidelines are beyond the scope of this article, but can be accessed online (https ://www.psych iatry .org/psych iatri sts/pract ice/telep sychi atry/toolk it/pract ice-guide lines ). mental health providers will need to make the most of potentially limited time for assessment and treatment, as clients with psychosis may not be able to tolerate long sessions via phone or video call. providers should aim to increase the frequency (and perhaps reduce the duration) of their client encounters (e.g., transition from one weekly -min session to twice weekly -min sessions). more frequent visits may provide greater opportunities for assessment of dynamic factors associated with increased risk of functional impairment, victimization, substance use, self-harm, violence, and change in housing or employment status. in addition, increased contact with members of the clinical team also provides more social contact during this period of physical distancing. communication and building trust over the phone are particularly challenging with clients with significant thought disorganization and paranoia, and providers will need to skillfully interweave engagement, assessment, and intervention strategies. providers may find it particularly difficult to assess and engage clients who are newly enrolled in services effectively via telehealth. a complete initial assessment and building a therapeutic relationship can be difficult over the phone. new clients may benefit most from at least an initial in-person visit to allow a more thorough intake assessment and diagnostic interview including physical observation and exam, as indicated. telemedicine using videoconferencing is the second-best option for new clients, with telephone encounters being used as a stop gap. notably, telehealth offers opportunities for environmental and interpersonal assessments that are not afforded during clinic visits, and these data may help to advance clients' functional recoveries. several targets for assessment and treatment should be prioritized for both new and existing clients, including safety assessment and management, psychological and pharmacotherapeutic strategies to manage psychiatric symptoms and co-occurring substance use disorders, assessment and management of physical health, and augmenting care by enlisting natural supports and employing asynchronous digital health interventions. comprehensive and effective community-based mental health treatment is essential to limit emergency room visits and inpatient psychiatric hospitalizations that increase risk of covid- exposure and further overload the health care system. along with clinic administrators, the medical director, and/or the risk management team, providers should weigh the risks and benefits of seeing a client who is at elevated risk of potentially lethal self-injurious behavior or violence toward others in-person versus via telehealth. clients who are less familiar to the clinical team, for whom historical and clinical risk factors are particularly high, or who are newly expressing behavioral intent to harm self or others should be prioritized for in-person care with appropriate measures to reduce risk of infection (ppe, physical distancing, etc.). as hospital beds may be even more difficult to access and some traditional clinic-based services will be reduced, administrators may need to re-deploy some outpatient clinical staff to outreach and crisis response teams to enhance capacity for both proactive and reactive contact with clients in-need, with appropriate precautions for both clients and staff. at the start of all telehealth and telephonic encounters, it is critical for the provider to obtain and document the client's phone number and current location. the phone number is important for technological troubleshooting, (client cannot access videoconference, or gets disconnected). an exact address from which they are calling is important to provide enough detail to direct emergency services to the client's location if necessary for a welfare check. it is imperative that safety plans are created and updated to ensure that all aspects of the plans are compatible with the restrictions in place in clients' immediate environments. if the client already has a safety plan, efforts should be made to ensure that the client has easy access to the plan in multiple modalities and that all aspects of the plan are feasible. depending on the nature of suicidal or homicidal ideation, distress tolerance will be most helpful to engage the client in down-regulation until the acute crisis remits. the my app (www.my ap p.org) adapts an evidence-based strategy for safety planning to a print or mobile application (stanley and brown ) . it is critically important for providers to identify triggers to suicidal urges; teach the client to look for affective, cognitive, or physiologic cues; and help the client to plan new responses when early warning signs emerge. ideally, natural supports-particularly those who live with the client-will contribute to identifying early warning signs and assist with adherence to the safety plan, if the client agrees to their participation. excessive worry, anxious avoidance, and insomnia are prevalent to high degrees in individuals suffering from mood and psychotic symptoms, represent putative causal factors for psychosis, and are each treatable intervention targets (freeman et al. ). in addition, poor self-regard-consisting of negative self-beliefs and low self-efficacy-are known correlates of both depression and psychosis (freeman ; sowislo and orth ). these important targets of in-person cognitive behavioral treatments of mood and psychotic disorders can also be addressed via remote care. during times of stress and uncertainty, clients may lapse into former, maladaptive habits. as providers and clients become more proficient in the use of telehealth, their intervention strategies more closely approximate in-person care (e.g., resuming prolonged exposure for ptsd; morland et al. ). in the interim, the priority during the public health crisis is to manage lapses in an effort to prevent relapse, acute decompensation, and risk behaviors. providers who are new to clients should rely heavily on befriending and engagement strategies before attempting to systematically intervene. even among existing clients, befriending and engagement strategies should be the fallback if the client becomes more reluctant to discuss delusions and hallucinations (kingdon and turkington ) after transitioning to telehealth. while symptom management strategies should be tailored to individuals' needs, preferences, and their ability to learn and practice new skills using e-mental health, all clients are likely to benefit from efforts to broaden their repertoire of distress tolerance skills for distressing beliefs and hallucinations, anxiety management strategies such as paced breathing, and behavioral activation, each of which are amenable to delivery in brief sessions (wright et al. ) to help manage distressing emotions. skills practice can be enhanced through virtual communities, websites, and-as detailed below-mobile health applications. as a transdiagnostic and translational model, cbt interventions for a variety of presenting problems can be delivered through telepsychiatry (mclay et al. ) . cbt and dbt skills training can help clients sustain gains and experience relief from emergent symptoms (matsumoto et al. ; stubbings et al. ) . telehealth may also be beneficial in understanding and addressing environmental contributors to symptoms, reducing no shows, and even improving engagement. although less studied, psychotherapy groups can also be offered through teletherapy (backhaus et al. ) , and some resources are available to support practitioners as they transition groups to videoconference (e.g., https :// mhttc netwo rk.org/). special attention should be given to individuals with substance use disorders, whether or not they were actively using substances prior to the pandemic. individuals with a history of substance use are at elevated risk of relapse, and urges to use should be normalized, monitored, and addressed with appropriate environmental, motivational, behavioral, cognitive, and-if applicable-pharmacologic interventions. individuals who are currently engaging in substance use may be particularly vulnerable to complications from covid- due to disproportionate rates of homelessness and incarceration compared to those without substance use, drug seeking behaviors that put them in close contact with others, and also effects of certain drugs on the lungs and respiratory system. in addition, practitioners must be mindful of the elevated risk of withdrawal syndromes related to sudden disruptions in the drug supply chain or inability to access medication-assisted treatment (mat). symptoms of withdrawal syndromes vary based on the substance, but can include increased anxiety and agitation, tremors, nausea, difficulty sleeping, increased psychotic and mood symptoms, and increased suicidal ideation. the provider should alert the client to these effects of discontinuation and promote harm reduction practices to balance safe discontinuation and consumption of substances. harm reduction approaches for clients with co-occurring substance use and psychiatric disorders during the covid- crisis should include maintaining frequent contacts across remote modalities (videocalls, phone, and texting, as available), generous use of befriending and normalization strategies, education on safer options for drug administration and drug administration sites, as well as a review of available mat options. in addition, providers can help clients develop strategies to promote safer social interactions that are acceptable to the client. emotion regulation strategies and distress tolerance skills that focus on activating the parasympathetic nervous system should be the main focus for these clients. among clients with cognitive impairment and/or disorganization, preference is given to depth over breadth to enhance overlearning. providers should coach the client to independently administer one or two skills that are effective in reducing subjective units of anxiety ( - %), rather than teaching a variety of these skills. clients should also identify a natural support they can access for skills coaching if a member of the cmhc's clinical team is not available for phone coaching, and that individual should be conferenced into remote clinical encounters whenever possible. community mental health providers are often the primary point of contact with the health care system for their clients with smi and represent the first responders to the covid- pandemic for many of these individuals. medical management during this time should target prevention strategies for covid- infection, management of physical health conditions in partnership with primary care and public health, support of smoking reduction or cessation, medication management, and lab monitoring. mental health providers need to be able to recognize the signs and symptoms of covid- illness, educate clients about basic strategies to recognize symptoms, and translate public health recommendations in ways that are comprehensible and implementable by clients. client-facing materials developed for general populations may need to be tailored to address limited health literacy (farrell et al. ) and promote more harm reduction strategies to mitigate viral exposure. providers can help clients problemsolve logistical barriers to reducing risks of infection, in some cases choosing among several options that are all associated with some risk. many social services and settings on which clients rely (e.g., clubhouses, food pantries, shelters) may be temporarily unavailable or present an unacceptable level of risk of infection. treatment plans that include clinic or pharmacy visits should specifically include strategies to reduce risk of covid- infection. risk mitigation strategies may be more challenging for some clients to implement due to cognitive challenges, interfering symptoms, and/or lack of skills on how to use or access key resources. as such, teams will need to translate cdc guidelines into more concrete behavior examples and use various means to model such behaviors visually. these may include demonstrating recommended hand washing techniques; personalized strategies for length of handwashing; use of disinfectant within the home, especially when living with others; specific guidance on how to navigate the environment if leaving the residence, such as understanding what more than six feet spatially looks like; application and removal of face masks; and modifying how one interacts with neighbors. such teaching may occur inperson while standing outside of the residence, or could be reviewed through videoconference if telehealth is possible. the mental health team should be aware of each client's pcp or help them establish care. it is important to coordinate with primary care, communicate about new respiratory symptoms, and advocate for evaluation and covid- testing as indicated. clients with respiratory symptoms should be advised to call pcp or er ahead rather than just showing up. in addition, coordinating with pcp and specialists may be needed to ensure ongoing treatment of chronic medical conditions in the midst of increased system strain and/or office closures, particularly for conditions that are correlated with a more severe coronavirus illness course (hu et al. ) . clients without housing, phones, or computers will face particular challenges getting their medical care needs met. behavioral health providers making outreach visits can be trained to assess vital signs. in some cases, funds have been allocated for purchasing communication hardware and/or data plans for clients in need. county and state public health departments are a resource for guidance on ppe recommendations in different settings, access to covid testing, and may have quarantine sites for those who are homeless or do not have sufficient space to isolate. public health departments should be contacted when clients are positive for covid, particularly if the client may have trouble following isolation guidelines secondary to impaired insight or judgment. public health may elect to conduct contact tracing and consider clients interactions at a mental health center, housing unit, or shelter. smoking increases both the risk of contracting covid- and the severity of illness. because the coronavirus targets the lungs, there is an increased urgency to quit smoking or vaping, or at least reduce use. this is an excellent time for mental health providers to focus on clients' efforts to quit. multiple medications are both effective in promoting smoking cessation among people with psychosis, and safe to use (not associated with increased risk of adverse neuropsychiatric side effects). in large clinical trials, varenicline appears to be the most effective medication to support smoking cessation among people with psychosis, but bupropion and nicotine replacement are also effective (anthenelli et al. ). combination nicotine therapy should also be considered, as this may increase the likelihood of success (stead et al. ). the clinical team should be apprised when pharmacotherapeutic interventions for smoking cessation are initiated, as mood and suicidal ideation should be monitored. clients should be advised that support is available through phone and texting services from - -quit-now ( - - - ), a free national phone service that routes the caller to the state line associated with caller's area code, and resources are also available from the american lung association, - -lung-usa ( - - - ), and the national cancer institute ( - u-quit ( - - ). in addition, there are a multitude of online resources to connect people to support groups and recommendations, including a government-sponsored website with information in english and spanish for adults and teenagers who smoke (smokefree: home) and a site from the american lung association, with a variety of tools to help quit both smoking and vaping (freedom from smoking) . apps may be particularly useful at this time. myquit coach offers different approaches to quitting smoking and community support. smoke free provides different techniques to quitting smoking, plus options and graphs to track cravings. virtual medication management visits should also be considered, as in-person visits pose a health risk not only to clients and providers, but also to elderly or medically-compromised individuals who live with clients or accompany them to clinic visits. there are unique challenges for telepsychiatry medication management visits for the treatment of psychosis and, to the extent possible, these should include video assessment. first, the evaluation of most medication side effects-including akathisia, parkinsonism, dystonic reactions, and tardive dyskinesia-is limited to self-report in telephone encounters. metabolic self-monitoring should be encouraged, especially among antipsychotic-naïve clients starting their first medication trial. clients with scales at home can weigh themselves and report these measures to the psychiatric care provider or nurse during the virtual encounter. second, the pandemic increases the risk of disruption to pharmacotherapy treatments. psychiatric care providers should review medication adherence and work with clients to ensure that they have an adequate supply of all both psychiatric and medical prescriptions, and a plan for refilling medications. the risks and benefits of a large supply of potentially lethal medications such as lithium or tricyclic antidepressants need to be weighed. weekly medication dispensing is still recommended for clients at high risk for suicide. for clients who have medications dispensed or observed weekly or more often, psychiatric providers might consider changing this medication support from in-person visits to daily phone calls. family support in picking up medications, pharmacy delivery services, and outreach by cmhc staff to drop off medications while observing from a safe distance are options to consider. there are two groups of clients who require special considerations with respect to pharmacotherapy management: those receiving long-acting injectable (lai) antipsychotic medications and those receiving clozapine. injections require physical proximity, yet proper ppe may not be reliably available to cmhc providers. clinics should provide large, well-ventilated areas for the administration of intramuscular injections and nurses should follow local ppe recommendations. it may be feasible to move clients from biweekly injections to other similar injectable formulations that can be given every weeks, or even every weeks. alternatives to in-person visits for lais should be considered on a case-by-case basis, as some clients may be able to tolerate a switch to oral medications during the period of reduction of in-clinic services, particularly if coupled with support from family or other natural or housing supports. there are several challenges in continuing high-quality clozapine treatment. treatment with clozapine in the prepandemic period required regular absolute neutrophil count (anc) monitoring (weekly for months, then bi-weekly for months, then monthly for the duration of treatment) to reduce the risk of a potentially life-threatening side effect of severe neutropenia. in the context of covid- , the clozapine risk evaluation and management strategy (rems)-the fda-mandated national program for reporting and monitoring clozapine treatment and adverse events-has published new guidelines for anc monitoring. the goal is to reduce the risk of contracting and/or transmitting covid- through laboratory visits (clozapine product manufacturers group ). the revised guidelines allow clients to continue receiving clozapine without a current anc. frequency of anc monitoring for any client should be determined using a shared decision-making process and should consider the risk of contracting covid in their community, the individual's risk of poor prognosis due to age and chronic medical conditions, their need to isolate due to covid- diagnosis or recent exposure, and their risk of severe neutropenia. at a minimum, clients should always be screened for covid- symptoms before in-person visits at the clinic or the lab. in most cases, it would be prudent to continue monitoring clients at their assigned frequency if their ancs have fallen below normal thresholds within the past months, or respective criteria for benign ethnic neutropenia (https ://www.cloza piner ems.com/cpmgc lozap ineui /rems/pdf/resou rces/anc_table .pdf). given that the highest risk for severe neutropenia is within months of clozapine initiation, clients in this phase warrant strong consideration for continued regular monitoring. for clients in biweekly or monthly phases of anc monitoring, the low risk of severe neutropenia makes a decision to forego regular monitoring a reasonable alternative, however a careful risk/ benefit evaluation needs to be conducted for each individual client. a decision to consider pausing anc monitoring for those no longer in weekly monitoring is consistent with a recently published consensus statement on the use of clozapine during the covid- pandemic (siskind et al. ) . along with reducing the anc testing frequency, it may be appropriate to increase the dispensed amount of clozapine up to -day supplies, based on a careful safety assessment of the individual client, with additional consideration of local pharmacy practices and insurance approval. additional challenges when initiating clozapine include monitoring vital signs for orthostatic hypotension and tachycardia, and monitoring for the increased risk of myocarditis. during the first month, serial troponins and c-reactive protein (crp) should be added to the weekly blood draw. lab monitoring should be accompanied by a targeted review of systems for myocarditis (e.g. chest pain, dyspnea, weakness, fever) and screening for other common side effects such as constipation, dizziness, weight gain, and sialorrhea. finally, it is important to remind clients taking clozapine for any duration that fever is a symptom shared with both severe neutropenia and covid- , and that if they develop a fever, they require urgent laboratory testing in order to rule out clozapine-associated neutropenia. in routine pharmacotherapy, lab tests are often required to measure therapeutic drug levels, monitor for renal or hepatic impairment, and screen and monitor for other side effects, including adverse metabolic effects. such monitoring may also be disrupted during the covid- pandemic, requiring adjustments to treatment. a client's laboratory may not be open or have reduced hours, or they may face barriers to getting to the lab. the psychiatric care provider and team should work with the client to weigh risks and benefits of each test for continued monitoring and consider the feasibility of alternative medications that do not require monitoring. even among clients who maintain ongoing services through multiple modes of care, as outlined above, behavioral health care can be enhanced or extended with asynchronous or selfguided technologies, including online resources and communities, technology-focused treatment adaptations, text messaging interventions, and provider-supported use of mobile health (mhealth) apps (andersson and cuijpers ). first, providers may extend services by coaching clients to access curated online resources, such as those offered by healthrelated, government, non-profits and advocacy organizations (e.g., mental health america ; national alliance on mental illness ; centers for disease control and prevention ). second, providers may consider adapting typical treatment strategies in a manner that involves increased client engagement with ordinary technologies, such as social media, videoconferencing platforms, or email, providing education and learning aids when necessary. other digital technologies such as smartphone applications can be used for direct mental health services, but the effectiveness of these interventions is enhanced by human support (mohr et al. ) . text messaging is highly accessible to individuals with serious mental illness. many individuals with smi own a device capable of texting (campbell et al. ) , and they use this feature at rates similar to the general population (noel et al. ) . text messaging has been repurposed to encourage illness management (granholm et al. ) , support medication adherence (montes et al. ) , and most recently, to provide ongoing therapeutic interaction with a designated member of the clinical team, i.e. a "mobile interventionist" (ben-zeev et al. ) . while text messaging offers the advantages of familiarity, ubiquity, and efficiency (schwebel and larimer ) , administrators must develop policies and procedures related to sms treatment guidelines prior to implementation and clinical adoption. providers should always use secure, encrypted platforms, establish protocols to protect client privacy, establish clear communication to clinic staff and clients about the parameters of text messaging (e.g., whether or not / access is available), and obtain informed consent when using text messaging. establishing these prerequisites in a cmhc that has not offered text messaging may take some time, but the asynchronous communication of text messages has several advantages. using this medium, providers can maintain ongoing interactions with multiple clients, and clients can access support in a discrete manner. other forms of digital health technologies allow clients to self-deliver evidence-based interventions. a growing body of research supports the use of smartphone apps to provide clients ongoing access to interventions. unfortunately, a few of the apps with the strongest evidence that have been designed specifically for users with serious mental illness are not yet publicly available. two such interventions-focus (ben-zeev et al. ) , which targets schizophrenia self-management, and prime (schlosser et al. ) , which targets social connection and depressive symptoms-have demonstrated efficacy and high rates of engagement in randomized trials. however, recent developments may assist providers in choosing an mhealth app for other clinical concerns-e.g. anxiety, insomnia, mindfulness-in the immediate term. psyberguide (neary and schueller ) is a non-profit project that publishes ratings of digital health apps along several categories, including credibility (e.g., the strength of empirical evidence for the app and its interventions), user experience (e.g., the design and overall experience for users), and transparency (e.g., clarity of an app's policies protecting user data, psyberguide ). mindtools.io (mindtools.io ) similarly provides ratings of popular digital mental health apps according to quality, credibility, research evidence, and security. providers can use these resources to better advise clients that are looking for mhealth support tools to use during disrupted clinical services. the covid- pandemic has indelibly shaped our healthcare system and our world. community mental health clinics are demonstrating resilience in the face of a mass trauma, and systems have the opportunity to experience posttraumatic growth as we begin to emerge from the pandemic. many of the changes that are being implemented to maintain care continuity during the pandemic can and should be maintained-at least in part-in its wake. experts are projecting that we will continue to see broader adoption of and applications for technology in behavioral health care moving forward (ben-zeev ) and that this new, more flexible and technology-enhanced model of care can benefit our clients' functional recoveries (ben-zeev et al. ) and may help to redress the mental healthcare disparities for underserved and marginalized populations (schueller et al. ). these include greater flexibility and creativity in the way that care is delivered, with a spectrum of options for remote and in-person care; greater integration of behavioral health and physical healthcare for existing conditions; tertiary prevention of contagious illnesses due to increased risk of exposure and deleterious health effects; increased collaboration and shared decision-making related to lai and clozapine use; updating safety plans and psychiatric advance directives to include new technologies and broader support systems; greater inclusion of natural supports; and integration of digital health interventions to treat primary and secondary psychiatric symptoms. to limit interpersonal contact, healthcare providers are rapidly pivoting to telehealth, encouraged by new centers for medicaid and medicare services' reimbursement codes for telehealth services (centers for medicare & medicaid services ). notably, cmhcs in states that have not elected to expand medicaid may consequently have more limited access to the practices and resources recommended here and may, as a result, observe higher rates of care discontinuity and/or poorer clinical outcomes during the pandemic response. providers and administrators have climbed a steep learning curve in a short timeframe. given that experts are projecting recurrent outbreaks, healthcare providers and mental health administrators will want to establish decision trees for determining medical, psychiatric, and social risks to diverse cmhc clients with corresponding care delivery options that balance risk to the individual, the clinical team, and the public. in particular, greater penetration of e-mental health may address both acute needs during the covid- crisis and chronic needs after the crisis subsides. policy makers and clinical administrators should attend not only to the emergent clinical gaps of today but also ways in which covid-related changes might inform future sustainable workflows, which will be particularly important if outbreaks are recurrent. funding dr. buck is currently supported by a career development award also from nimh (k mh ) as well as a narsad young investigator award from the brain and behavior foundation. priorities for the us health community responding to covid- . jama: the journal of the internet-based and other computerized psychological treatments for adult depression: a metaanalysis neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (eagles): a double-blind, randomised, placebo-controlled clinical trial. the lancet videoconferencing psychotherapy: a systematic review telephone-delivered psychosocial interventions targeting key health priorities in adults with a psychotic disorder: systematic review the digital mental health genie is out of the bottle mobile health (mhealth) versus clinic-based group intervention for people with serious mental illness: a randomized controlled trial a technology-assisted life of recovery from psychosis remote "hovering" with individuals with psychotic disorders and substance use: feasibility, engagement, and therapeutic alliance with a textmessaging mobile interventionist cell phone ownership and use among mental health outpatients in the usa medicare telemedicine health care provider facts racial health disparities and covid- -caution and context ocr announces notification of enforcement discretion for telehealth remote communications during the covid- nationwide public health emergency addressing the covid- pandemic in populations with serious mental illness examining health literacy levels in homeless persons and vulnerably housed persons with mental health disorders persecutory delusions: a cognitive perspective on understanding and treatment treatable clinical intervention targets for patients with schizophrenia mobile assessment and treatment for schizophrenia (mats): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations for telehealth to succeed, privacy and security risks must be identified and addressed stressed over covid- ? text new hotline for help from local counselors. the southern illinoisan prevalence and severity of coronavirus disease (covid- ): a systematic review and meta-analysis telepsychiatry in the assessment and treatment of schizophrenia cognitive therapy of schizophrenia: guides to evidence-based practice e-mental health: a rapid review of the literature internet-based cognitive behavioral therapy with real-time therapist support via videoconference for patients with obsessive-compulsive disorder, panic disorder, and social anxiety disorder: pilot single-arm trial systematic review of telehealth interventions for the treatment of sleep problems in children and adolescents mental health and covid- -information and resources about mindtools.io. retrieved supportive accountability: a model for providing human support to enhance adherence to ehealth interventions a short message service (sms)-based strategy for enhancing adherence to antipsychotic medication in schizophrenia home-based delivery of variable length prolonged exposure therapy: a comparison of clinical efficacy between service modalities state of the field of mental health apps use of mobile and computer devices to support recovery in people with serious mental illness: survey study app guide. retrieved telepsychiatry: overcoming barriers to implementation efficacy of prime, a mobile app intervention designed to improve motivation in young people with schizophrenia policy determinants affect telehealth implementation use of digital mental health for marginalized and underserved populations using text message reminders in health care services: a narrative literature review. internet interventions the need for telepsychiatry and e-mental health in publicly-funded mental health systems consensus statement on the use of clozapine during the covid- pandemic does low self-esteem predict depression and anxiety? a meta-analysis of longitudinal studies safety planning intervention: a brief intervention to mitigate suicide risk nicotine replacement therapy for smoking cessation comparing in-person to videoconference-based cognitive behavioral therapy for mood and anxiety disorders: randomized controlled trial covid- and health equity-a new kind of "herd immunity high-yield cognitive-behavior therapy for brief sessions: an illustrated guide ethical approval in the past years, dr. jarskog has received research grant funding from auspex/teva, boehringer-ingelheim, and otsuka; he has served as a consultant to uptodate and bracket. no other authors have conflicts of interest to disclose. all authors certify responsibility for the content of this article. this work does report on research involving human participants or animal subjects and did not require ethical approval from an institutional review board. key: cord- -b dksrbx authors: sukut, ozge; ayhan balik, cemile hürrem title: the impact of covid‐ pandemic on people with severe mental illness date: - - journal: perspect psychiatr care doi: . /ppc. sha: doc_id: cord_uid: b dksrbx purpose: the purpose of this review was to address the impact of the covid‐ pandemic on people with severe mental illness. conclusion: given the psychosocial effects of the covid‐ pandemic process and the vulnerability of individuals with mental illness, it is clear that some preventive measures will increase the well‐being of these individuals and reduce relapses. careful planning and execution of preventive measures to be taken at the individual, institutional, and social level are essential to minimize the negative consequences of this pandemic for this vulnerable population. practice implications: the results of this first review on the topic provide preliminary support for effectively address the needs and healthcare necessities of individuals with serious mental illness by raising awareness among healthcare workers during the covid‐ pandemic. patients have been mentioned during the covid- epidemic around the world, it has been less emphasized that the difficulties experienced by individuals with mental disorders. ignoring the effect of the outbreak on people with mental illness will not only inhibit the measures taken to prevent further spread of covid- , but also increase existing health inequalities. outbreaks do not affect the whole population equally in countries. some vulnerable groups may be more indefensible to infection as well as more negatively from the virus and the process. understanding the effect on individuals with mental health illness of the outbreak, it is necessary and important to protect these individuals who are a vulnerable group and provide the health services they need. by the outbreak of covid- . for example, the beginning of february , about inpatients diagnosed by wuhan mental health center and on february , , totally patients with mental health disorders were infected by covid- . the sudden increase of the cases has raised concerns about the role of mental disorders in the transmission of coronavirus infection. . | the nature of psychiatric illness and infectious disease the individual with severe mental illness are more sensitive against infection for various reasons such as decreasing cognitive ability and awareness of self-care, using medication continuously and limited conditions in psychiatry clinics. one of the risk factors for the transmission of infection in psychotic patients is the lack of insight of the patient. this can lead to an increase the risk of infection, including pneumonia, in individuals with mental health illness. it is known that infections transmitted from person to person through droplet or close contact spread more easily, especially in limited areas. inpatients, such as closed or chronic psychiatric clinics, may have a higher risk of cluster contamination, particularly in closed clinics. the importance of preventive measures is strongly emphasized, especially in viral droplet infections. the psychiatry clinics are not designed according to the isolation standards for respiratory diseases like other clinics, and the equipment also may be inadequate in this regard. besides psychiatry patients are more resistant to the isolation process. therefore, sometimes it is harder to cooperate with patients. patients with no insight are not aware of the changes in their environment and they can't protect their self from the external environment. . | the difficulties of management of preventive strategies for people with severe mental illness the preventive strategies are very important until a vaccine or treatment is found for viral infections. the standard recommendations, like washing hand with soap and water, covering the mouth and nose while sneezing or coughing, cooking to food well-done, avoiding close contact with anyone who has symptoms with respiratory diseases, prevent the spread of infections can be difficult to individuals who has chronic disease as well as mental health disorders. individuals with serious mental disorders may not only be vulnerable to easy transmission of infection, but can also play a role in the transmission and self-quarantine prevention in this population can pose several that population. in addition to the practical difficulties in practice, even - months after the quarantine, there may be further deterioration in mental state, including anger and anxiety. [ ] [ ] [ ] . | the effect of psychosocial problems caused by covid- among people with severe mental illness covid- outbreak also causes the fear and anxiety. prevention measures such as isolation and quarantine can lead to fear, anxiety, and uncertainty for patients, causing to increase the diseases related with stress and at the same time it can cause exacerbation of pre-existing mental disorders. , individuals with mental health disorders are more affected by the emotional reactions due to covid- outbreaks and it can lead to relapse and worsening their conditions. individuals with mental disorders are more vulnerable to stress when compared with the general population. relapse in serious mental disorders can cause poor hygiene, not being able to implement social distance or other preventive strategies, not reporting in a timely manner or getting medical help, and nonadherence expected treatment. life-related risk factors such as obesity, physical inactivity and smoking have caused cause medical conditions that result in increased mortality and morbidity in people with mental disorders. it is estimated that there is a - -year shortening in the average life expectancy of individuals with severe mental disorders. cardiovascular disease, coronary heart disease and type diabetes are the most common medical conditions in this population. , high smoking rate among these individuals may increase the infection risk and is an indicator of poor prognosis among those who develop the disease. it has also known that housing problems and homelessness could increase the risk of infection and make the diagnosis, follow-up and treatment difficult in infected people. [ ] [ ] [ ] at the same time, these individuals have lacked health insurance that coverage to diagnostic test or treatment due to problems such as unemployment. small social networks have limited opportunities to get support from friends and family members if they get sick in these individuals with serious mental illness. within this scope, these factors have led to higher rates of infection and poor prognosis in this population. . | the effect of covid- on adherence to treatment among people with severe mental illness it also known that the risk of infection among people with serious mental illness have increased because of going to the outpatient visit for follow-ups and prescriptions. as a result of the traffic restrictions and social isolation preventions applied due to the covid- pandemic, patients receiving outpatient treatment due to serious mental illness have difficulty maintaining their treatment. therefore, precautions taken due to the outbreak can cause relapses and behaviors such as hyperactivity, agitation, self-harm, and others. therefore, these preventive measures which also increase the risk of suicide and negative emotions can lead to a decrease in the well-being of individuals with serious mental illness. as a result, these individuals may experience feelings such as loneliness, denial, anxiety, depression, insomnia, and hopelessness that may decrease the compliance to treatment. social stress factors that can trigger serious mental disorders such as depression or anxiety in previously healthy people, such as health anxiety, fear of death, loss of loved ones, loss of social connectedness, loss of employment and homelessness can cause more serious problems in individuals with serious mental illness. prevention strategies as like social isolation developed for the general population can be difficult to apply due to conditions such as limited health literacy in these individuals. it is important that to organize these measures to address the challenges mentioned. it will also be important to address the psychological and social dimensions of the covid- outbreak for psychiatric patients. social support systems should be activated, because social isolation strategies that are critical to reduce the spread of the disease can also increase the risk of isolation and loneliness in this population. some of the proposed interventions include managing common stress symptoms (sleep hygiene, relaxation etc.), promoting prevention strategies related to infection, limiting exposure to misinformation through the media, promoting problem-solving and self-efficacy. relaps symptoms, such as self-harm or treatment adherence which may develop due to outpatient treatment during the outbreak, should also be considered. individual-centered care included the need for flexibility and taken a holistic approach at the center of contemporary mental health practice should be provided to these patients. the authors declare that there are no conflict of interests. the psychological impact of quarantine and how to reduce it: rapid review of the evidence priorities for the us health community responding to covid- timely mental health care for the novel coronavirus outbreak is urgently needed. the lancet patients with mental health disorders in the covid- epidemic iranian mental health during the covid- epidemic progression of mental health services during the covid- outbreak in china risk of pneumonia and pneumococcal disease in people with severe mental illness: english record linkage studies the risk and prevention of novel coronavirus pneumonia infections among inpatients in psychiatric hospitals seasonal flu guidance for to for healthcare and custodial staff in prisons, immigration removal centers and other prescribed places of detention for adults in england outbreak of pandemic virus (h n ) in a residence for mentally disabled persons in balearic island mental health status of people isolated due to middle east respiratory syndrome covid- in people with mental illness: challenges and vulnerabilities caring for persons in detention suffering with mental illness during the covid- outbreak psychological interventions for people affected by the covid- epidemic mortality and medical comorbidity in the severely mentally ill: a german registry study mental illness and metabolic syndrome-a literature review comorbidity of mental and physical diseases: a main challenge for medicine of the st century addressing the covid- pandemic in populations with serious mental illness smoking or vaping may increase the risk of severe coronavirus infection covid- : a potential public health problem for homeless populations expert consensus on managing pathway and coping strategies for patients with mental disorders during prevention and control of infectious disease outbreak psychosomatic health service intervention plan for the prevention and control of new coronavirus infection and pneumonia the covid- outbreak: crucial role the psychiatrists can play how to cite this article: sukut o, ayhan balik ch. the impact of covid- pandemic on people with severe mental illness key: cord- -pyg vwb authors: tabak, tom; purver, matthew title: temporal mental health dynamics on social media date: - - journal: nan doi: nan sha: doc_id: cord_uid: pyg vwb we describe a set of experiments for building a temporal mental health dynamics system. we utilise a pre-existing methodology for distant-supervision of mental health data mining from social media platforms and deploy the system during the global covid- pandemic as a case study. despite the challenging nature of the task, we produce encouraging results, both explicit to the global pandemic and implicit to a global phenomenon, christmas depression, supported by the literature. we propose a methodology for providing insight into temporal mental health dynamics to be utilised for strategic decision-making. mental health issues pose a significant threat to the general population. quantifiable data sources pertaining to mental health are scarce in comparison to physical health data (coppersmith et al. ). this scarcity contributes to the complexity of development of reliable diagnoses and effective treatment of mental health issues as is the norm in physical health (righetti-veltema et al. ). the scarcity is partially due to complexity and variation in underlying causes of mental illness. furthermore, the traditional method for gathering population-level mental health data, behavioral surveys, is costly and often delayed (de choudhury, counts & horvitz b) . whilst widespread adoption and engagement in social media platforms has provided researchers with a plentiful data source for a variety of tasks, including mental health diagnosis; it has not, yet, yielded a concrete solution to mental health diagnosis (ayers et al. ) . conducting mental health diagnosis tasks on social media data presents its own set of challenges: the users' option of conveying a particular public persona posts that may not be genuine; sampling from a sub-population that is either technologically savvy, which may lend to a generational bias, or those that can afford the financial cost of the technology, which may lead to a demographic bias. however, the richness and diversity of the available data's content make it an attractive data source. quantifiable data from social media platforms is by nature social and crucially (in the context of our cases study) virtual. quantifiable social media data enables researchers to develop methodologies for distant mental health diagnosis and analyse different mental illnesses (de choudhury, counts & horvitz a) . distant detection and analysis enables researchers to monitor relationships of temporal mental health dynamics to adverse conditions such as war, economic crisis or a pandemic such as the coronavirus (covid- ) pandemic. covid- , a novel virus, proved to be fatal in many cases during the global pandemic that started in . governments reacted to the pandemic by placing measures restricting the movement of people on and within their borders in an attempt to slow the spread of the virus. the restrictions came in the form of many consecutive temporary policies that varied across countries in their execution. we focus on arguably the most disruptive measure: the national lockdown. this required individuals, other than essential workers (e.g. healthcare professionals) to remain in their own homes. the lockdown enforcement varied across countries but the premise was that individuals were only permitted to leave their homes briefly for essential shopping (food and medicine). this policy had far reaching social and economic impacts: growing concern towards individuals' own and their families' health, economic well-being and financial uncertainty as certain industries (such as hospitality, retail and travel) suspended operations. as a result, many individuals became redundant and unemployed which constrained their financial resources as well as being confined to their homes, resulted in excess leisure time. these experiences along with the uncertainty of the measures' duration reflected a unique period where the general public would be experiencing a similar stressful and anxious period, which are both feelings associated with clinical depression (hecht et al. , rickels & schweizer . in this paper, we investigate the task of detecting whether a user is diagnosis-worthy over a given period of time and explore what might this appropriate time period be. we investigate the role of balance of classes in datsets by experimenting with a variety of training regimes. finally, we examine the temporal mental health dynamics in relations to the respective national lockdowns and investigate how these temporal mental health dynamics varied across countries highly-disrupted by the pandemic. our main contributions in this paper are: ) we demonstrate an improvement in mental health detection performance with increasingly enriched sample representations. ) we highlight the importance of the balance in classes of the training dataset whilst remaining aware of an approximated expected balance of classes in the unsupervised (test) dataset. ) we analyse empirically proven relationships between populations' temporal mental health dynamics and respective national lockdowns that can be used for strategic decision-making purposes. unlike physical health conditions that often show physical symptoms, mental health is often reflected by more subtle symptoms (chung & pennebaker , de choudhury, counts & horvitz a . this yielded a body of work that focused on linguistic analysis of lexical and semantic uses in speech, such as diagnosing a patient with depression and paranoia (oxman et al. ) . furthermore, an examination of college students essays, found an increased use of negative emotional lexical content in the group of students that had high scores on depression scales (rude et al. ) . such findings confirmed that language can be an indicator of an individuals psychological state (bucci & freedman ) which lead to the development of linguistic enquiry and word count (liwc) software (pennebaker et al. , tausczik & pennebaker which allows users to evaluate texts based on word counts in a variety of categories. more recent and larger scale computational linguistics have been applied in conversational counselling by utilising data from an sms service where vulnerable users can engage in therapeutic discussion with counsellors (althoff et al. ) . for a more in-depth review of uses of natural language processing (nlp) techniques applied in mental health the reader is referred to trotzek et al. ( ) . the widespread engagement in social media platforms by users coupled with the availability of platforms data enables researchers to extract population-level health information that make it possible to track diseases, medications and symptoms (paul & dredze ) . the use of social media data is attractive to researchers not only due to its vast domain coverage but also due to the cheap methodologies by which data can be collected in comparison to previously available methodologies (coppersmith et al. ) . a plethora of mental health monitoring literature have utilised this cheap and efficient data mining methodologies from a variety of social media platforms such as: reddit (losada & crestani ) , facebook (guntuku et al. ) and twitter (de choudhury, gamon, counts, & horvitz ). twitter user's engagement in the popular social media platform give way for the creation of social patterns that can be analysed by researchers, making this platform a widely used data source for data mining. additionally, the customisable parameters querying available in the application programmable interface (api) allows researchers to monitor specific populations and/or domains (de choudhury, counts & horvitz b). in the context of the covid- pandemic, we found a handful of projects with similar intentions as our own, to mon-itor depression during the pandemic. li et al. ( ) gather large scale, pandemic-related twitter data and infers depression based on emotional characteristics and sentiment analysis of tweets. zhou et al. ( ) focus on detecting community level depression in australia during the pandemic. they use the distant-supervision methodologies of shen et al. ( ) to gather a balanced dataset, they utilise the methodology of coppersmith et al. ( ) to model the rates of depression and observing the relationship with the number of covid- infections in the community. our work differs from this in three main areas: ) we investigate the implication of different sample representations to provide more context to our classifier. ) we retain an imbalance in our development dataset. ) we investigate european countries (france, germany, italy, spain and the united kingdom) that experienced a relatively high number of covid- infections. in this section we describe the data mining methodology used to build a distantly supervised dataset and the classifier experiments conducted on this dataset. to conduct the proposed experiments, we firstly construct a distantly supervised development dataset for each country, to be used in training and validation of the classifier. the data mining methods follow the novel distant-supervision methodology proposed in coppersmith et al. ( ) as it is relatively cheap but also well-structured for clinical experiments. we follow the widely-accepted methodology proposed by watson ( ) where diagnosed (diagnosed) and nondiagnosed (control), groups are created. in this paper we will only be exploring depression as a mental health condition, accordingly we will have a single diagnosed group for each country's development dataset. however, if multiple mental issues were to be explored, then the same number of different diagnosed groups would be required for each country's dataset. ) diagnosed group: we gather public tweets with a geolocation inside the country of interest, posted during a two-week period during . as we are searching for a depression diagnosed tweets, this two-week period needs to be chosen strategically, as we want to capture users that have been diagnosed with depression rather than seasonal affect disorder (sad), a separate albeit a condition with similar symptoms. tweets collected via twitters api , were retrieved based on lexical content indicating that the user has history/is currently dealing with a clinical case, e.g. i was diagnosed with depression, rather than expressing depression in a colloquial context. human annotators were then instructed to remove tweets that are perceived to have made a nongenuine statement regarding the users' own diagnosis, most of these were referring to a third party. examples of genuine and non-genuine tweets encountered can be seen in table i . we then collect all (up to , most recent) tweets made public by the remaining users between the start of and october . further filtering includes removal of all users with less than tweets during this period or those whose tweets do not meet our major language of instruction benchmark. this benchmark requires % of the tweets collected to be written in the major language of instruction of the country of interest (i.e. united kingdom is english, italy is italian etc.). following this filtering process and some preprocessing on the tweet level, which includes medial capital splitting, mention white-space removal (i.e. if another user was mentioned this will be shown as a unique mention token), the same has been done with urls, all uppercase and non-emoticon related punctuation were removed. ) control group: we gather , public tweets with a geolocation in the country of interest, posted during the same two-week period as the diagnosed in and remove any tweets made by diagnosed group users. we then follow a similar process to that of the diagnosed collection methodology by collecting up to , most recent tweets for each user from the period mentioned above. as can be seen in table ii , we construct imbalanced datasets. world health organisation (who) claim million people suffer from depression worldwide . whilst, at the time of writing, the global population is approximately . billion . this would suggest that in individuals suffer from depression. however, these figures are approximations. therefore, the extent to which our datasets are imbalanced is not an attempt to create datasets that are representative of the expected balance of classes, as these are unverifiable. nevertheless, our datasets present ratios of control:diagnosed samples between . : and . : , which came about from the data mining methods previously described. we accept these ratios to retain imbalanced datasets in a similar order of magnitude as the expected balance whilst achieving reasonable classifier performance. we inherit the caveats to the distantsupervision approach of coppersmith et al. ( ) : (a) when sampling a population we always run the risk of only capturing a subpopulation of the control or diagnosed that is not fully representative of the population, especially considering that diagnosed samples are identified based on the fact that they publicly speak out about what is a deeply personal subject this attribute may not generalise well to the entire population. (b) we do not implement a verification of the method used to identify users in diagnosed but rather rely on the social stigma around mental illness whereas it could be regarded as unusual for a user to tweet about a diagnosis of a mental health illness that is fictitious. (c) control is likely contaminated with users that are diagnosed with a variety of conditions, perhaps mental health related, whether they explicitly mention this or not. we have made no attempt to remove such users. (d) depression is often comorbid with other mental health issues (aina & susman ) . as such, it is plausible that the users forming diagnosed are suffering from other mental health conditions. this could suggest that the classifier will be trained to pick up these hidden meaning representations of other mental health issues and classify them as depression. we have made no attempt to further investigate nor remove such users from diagnosed as having a complex diagnosed group is a realistic representation of the task. in this section we describe the experiments conducted in training our classifier to diagnose depression. the trained classifier is deployed in section iv for classifying samples from an unsupervised experiment dataset which is then used in analysing temporal mental health dynamics. we investigate the most appropriate sample representation of our distantly supervised dataset. we are posed with these considerations: (a) symptoms' temporal dependencies: as the tweets gathered come from a variety of days, weeks, months and even years, symptoms may only be present in specific timedependant samples. however, when represented by overwhelming tweet-enriched samples the classifier perfor-mance is traded-off with retaining the symptoms' temporal dependencies. (b) as our final task will be to monitor and analyse the temporal mental health dynamics, we are interested in modelling the rate of depression as fine-grained as possible. therefore, the ability to accurately identify diagnosed samples and correctly discriminate between control and diagnosed with the least tweet-enriched samples will be vital in modelling a fine-grained rate of depression in the deployment stage of the final task where conclusions could be drawn in the context of the national lockdowns. the sample representations we examined: • individual each sample constitutes of a single tweet. • u ser day -each sample constitutes of all tweets by a unique user made public during a given day. • u ser week each sample constitutes of all tweets by a unique user made public during a given week. • all user -each sample constitutes of all tweets made public by a unique user. we examine the performance of a benchmark, support vector machine (svm) with a linear kernel function (peng et al. ) , on the different sample representations datasets where the benchmark classifier inputs are sparse many-hot encoding representations of the samples' lexical content. as we are working with imbalanced datasets we need to think about the metrics we use to assess the classifiers' performance. the accuracy metric is insufficient for imbalanced datasets and is best illustrated with an example. if we have a dataset with : ratio split between the samples of each class, the classifier could achieve % accuracy by classifying every sample as the majority class. the classifier is clearly not discriminating between the distributions of the two classes but yet achieving high performance. as such, we will be assessing the performance of the classifier on the individual classes' precision (p), recall (r) and f score measures as well as the macro f score for this and the remainder of the experiments in this paper. the precision measure will tell us: of all the samples the classifier labelled as a particular class, what fraction are correct. the recall measure will tell us: of all the samples that actually belong to that particular class, how many did the classifier correctly identify. whilst the f score is a harmonic mean between the two and the macro f score takes the f scores of all classes and calculated a non-weighted mean between them. by having a more classspecific breakdown of the classifiers' performance we can better understand the strengths and limitations of our classifiers and hence make a more informed decision when choosing the highest performing classifier. the results in table iii suggest that our benchmark classifier improved in identifying diagnosed, with increasingly tweet-enriched, samples. interestingly however, when presented with the u ser day sample representations a sharp decreased in performance in control samples causing a decrease in macro f score when compared with the f scores of both individual and u ser week sample representations. barring this decrease in macro f score, we can say that we are able to achieve improved performance when using increasingly tweet-enriched samples. however, the end task would benefit from fine-grained modelling of the rate of depression, providing us with more detailed relationships between the temporal mental health dynamics and noteworthy dates. as such, our task is bias towards the two fine-grained sample representations, individual and u ser day. as our benchmark classifier achieves superior performance on the individual sample representation we will adopt this representation, as denoted by the asterisk in table iii . ) classifier experiments on u.k. development dataset: once we have chosen the sample representation that balances out or fine-grained sample requirements with the benchmark classifier performance, we must now build a classifier that best discriminates between our two classes. the higher the performance of the classifier, the more accurate the temporal mental health dynamics will in section iv. we outline the classifier architectures included in our experimentation: • sv m : linear kernel svm as used in section iii-b . this classifier will serve as our benchmark. • av ep l ef c : average pooling layer. we set hyper-parameters where an adam optimiser (kingma & ba ) is used with a learning rate of . , batch size of , . all classifiers were trained for a single epoch with a dataset training:validation split of : and weighting the samples of diagnosed as times more valuable than those of control. training was done on a single tesla p -pcie with gb of ram available through google's colaboratory . table iv shows that all classifiers achieve significantly higher performance on control than diagnosed. as we are trying to correctly detect diagnosed samples and discriminate between the two classes, we prioritise the diagnosed precision and macro f score metrics. based on these chosen metrics to guide our classifier selection process candidates emerge: av ep l, bilst m and bilst m -self a achieving {diagnosed precision, macro f } scores of: { . , . }; { . , . } and { . , . } respectively. whilst the performance of these classifiers is similar the performance of bilst m -self a is the highest performance combination of the desired metrics (indicated by the asterisk) and as such we will be adopting this classifier in further experiments. in this section we investigate the distribution of our datasets in training and validation of our classifier. by conducting this experiment we intend to gather an in-depth understanding of our task from a linguistic standpoint. we train and validate the classifier on datasets with varying balances to investigate the role of our imbalanced dataset in the depression diagnosis task. this experiment analyses the performance of the bilst m -self a classifier on a number of different training regimes: • balanced: a dataset containing all diagnosed samples and downsampling from control. • imbalanced: a dataset of the development dataset's distribution (see table ii) . furthermore, we explore the effects of sample weighting of the classes by weighting diagnosed samples as times more valuable than control samples as mentioned in the previous experiment. the performance of the bilst m -self a classifier on the different training regimes can be seen in table v the balanced-balanced (t raining-v alidation) training regime achieves encouraging results in terms of its precision-recall trade-off, for both classes, as well as the macro f score. this shows that the problem is reasonably linguistically achievable, when the imbalance challenge is removed from the equation. the imbalanced-imbalanced training regime shows that adjusting the sample weighting is a successful measure we can implement to adjust the precision-recall trade-off in our class of interest (diagnosed). our classifier performs significantly worse in the balanced-imbalanced regime when compared to the performance on the imbalanced-imbalanced regime, this performance is reduced by the introduction of sample weighting. this means that when training on a balanced dataset our classifier is less robust to an imbalanced dataset at validation. finally, whilst our classifier experiences a significant improvement in performance on the imbalanced-balanced training regime when sample weighting is introduced due to our final depression diagnosis task in which we expect an imbalanced unsupervised dataset (discussed in section iii-a ) the training regimes implementing balanced validation datasets are not suitable approximations of our classifier's depression diagnosis performance. therefore, we conclude that imbalanced training, with suitable sample weighting, yields more desirable and robust depression diagnosis performance as it's able to see a broader range of data examples in training (i.e. no sub-sampling). we train separate bilst m -self a classifiers for each of the countries' imbalanced development datasets following the individual sample representation. the test performance of these classifiers can be seen in table vi . we observe that the bilst m -self a classifier architecture achieved similar performance on the remaining countries' datasets as was acheived on u.k. dataset. this shows that the bilst m -self a architecture is able to generalise well to different languages and cultural differences after training. hence, producing an encouraging set of results and increase our confidence in its classification ability. whilst the bilst m -self a classifier architecture achieved the highest performance of all our classifier architectures, a combination of . diagnosed precision and . macro f score leaves much to be desired. as such, we perform an error analysis and examine the significance of its results. table vii shows the input samples, text, the prediction type as well as the sigmoid output which is the output layer of the classifier and is responsible for the final classification of the samples. the sigmoid output is normalised in the range of [ , ] ∈ r, where an output of . represent the decision boundary, as such it can be interpreted as complete uncertainty by the classifier as to how the sample should be classified. a sigmoid output of is complete certainty that the sample should be classified as positive (diagnosed) and an output of is complete certainty the sample should be classified as negative (control). we observe that the true positive example mentions having "overcoming depression" which implies that the user has recovered from depression, as one overcomes other health issues. the sigmoid output for this sample is . which is extremely high certainty by the classifier that this sample follows the distribution of diagnosed. whilst on the other end of the scale, the true negative sample discusses a topic that is completely unrelated to nor implies that the individual suffers from depression, as such it is classified as part of control with a sigmoid output of . . however, we find the texts of the two samples misclassified by the classifier are rather similar. they both use words rooted from the word 'depress' in rather colloquial contexts, with no indication of a past diagnosis or clinical appropriation of depression -which is rather a desirable ability for our classifier to be able to discriminate between. it is also noteworthy that the sigmoid outputs of these two samples are much less polarised than the correctly classified samples, with the sigmoid output of the false positive sample just about falls within the diagnosed classification region. however, these two incorrectly classified samples reflect the complexity of depression diagnosis from distantly supervised tweets. ) significance of results: we investigate the significance of our classifiers' results by performing a χ significance test. our null hypothesis, h , states that both sets of data, our classifiers' predictions (d p ) and the distribution it is being tested against (d t ), have been drawn from the same distribution (d). we compare the distribution of the classifiers' predictions against a random uniformly distributed set (denoted by uniform) and against a random distributed set following the distribution of the development datasets (denoted by weighted). all classifier results in table vi are statistically significant from the random baselines, according to the χ significance testsee table viii in appendix a. therefore, we can reject h and conclude that the predictions of the classifier and those of the respective randomly distributed benchmarks have not been drawn from the same distribution. we prepare the unsupervised dataset and deploy the previously trained bilst m -self a classifier to annotate this dataset. we analyse the relationships between the temporal mental health dynamics to respective national lockdown dates. in this section we discuss the procedure for constructing the unsupervised experiment dataset, to be used for monitoring the temporal mental health dynamics during the respective pandemic-inflicted national lockdowns. the experiment dataset is used for the deployment of the classifier, which is trained and validated on the development set, to analyse the temporal mental health dynamics of a country. we start by gathering tweets made public by users during the first two weeks of with a geolocation within the country of interest. we then follow the same methodology for data mining as control outlined in section iii-a, for the periods starting from december until may , where we apply similar user-level and tweet-level preprocessing and filtering on these dataset. the composition of these experiment datasets can be seen ( table ix in appendix b) along with key dates. the key dates specified observe the official date announcing the commencement of and the announcement of first step towards easing of the national lockdowns, rather than the first official data implementing these measures as we anticipate that the announcement would provoke users to express their opinion more than the implementation of the measures. we acknowledge some caveats to the methodology with relations to the temporal mental health dynamics during the respective national lockdowns: (a) the activity-level of users whose lifestyles have been highly disrupted by the national lockdowns may be overstated during this period, due to increased leisure time. (b) the language-based filtering component may exclude certain users of the population such as stranded expatriates that use a non-majority language to communicate their thoughts. such samples may contain a bias towards a higher rate of depression. to monitor and analyse temporal mental health dynamics we must firstly deploy our trained bilst m -self a on the respective countries' unsupervised experiment datasets. once we have the classifier's predictions, we must model the rate of depression by calculating the rate of depression at any given day, r t , using the following equation: where Φ represents our trained classifier, x i is the input, n t is the total number of samples on day t. the output of the classifier, Φ(x i ) takes the form [ , ] ∈ n. r t is a normalised continuous value between and , interpreted as the proportion of tweets at t that classify as diagnosed: meaning all samples belong to control and meaning all samples belong to diagnosed. figures and (see appendix c) display the temporal mental health dynamics for the countries under investigation. it is noteworthy that r t across the different countries is a function of the ratio of control:diagnosed samples in the country specific datasets on which the classifier was trained. as such, the rates across countries are not directly comparable but are rather analysed by the momentum of how r t in a country changed over time and how it differed from r t of other countries. foremost, we note that we categorically cannot, nor do we, state that the rates of depression discussed in this section are caused by the imposition of respective national lockdowns or any other measures of any type, taken by governments to combat the spread of the virus. in this section, we merely offer interpretations of the rates of depression in line with explicit relationships that we discover between the rates of depression and key events that occurred during the time-period included in this case study. upon examination of the u.k. rate of depression (r u k ), the first distinct observation we make is not related to any pandemic-related measures but rather the sharp, non-sustained, increase of r u k of over % on christmas day, before decreasing back to the status quo the next day. upon further investigation we find that this phenomenon is well-documented (hillard & buckman ) and seeing that our classifier was able to identify this phenomenon, without explicitly being aware of its existence, is encouraging. we continue observing r u k chronologically, on march th , italy national lockdown begins. from this point on we observe a sharp, sustained increase in r u k approximately until march rd , u.k. national lockdown begins (the last country to impose such a restriction in this study), where r u k somewhat plateaus. we interpret this as an increase in anxiety, a symptom of depression, amongst the u.k. population as neighbouring countries take decisive measures to slow the spread. a key theme in the build up to the u.k. national lockdown implementation was the intentional delay so that to ensure maximum utility from the policy . however, a report published on the th of march by the imperial college covid- response team estimated that the the current combative approach taken up by the u.k. government would result in , deaths. the report was well-publicized by the british media and was arguably a factor in the change of combative approach by the u.k. government. this is somewhat supported by the change in r u k during the u.k. national lockdown where we see a sustained decrease for the majority of the period. finally, we observe a slight increase in r u k towards the end of and in the aftermath of the national lockdown that could perhaps be interpreted as anxiety and concern from the population at the uncertainty with which they are faced both from a social and an economic perspective. the rates of depression of france (r f r ), germany (r de ), italy (r it ) and spain (r es ) behave rather differently from r u k . firstly, r it increases sharply by over % over the initial days of the italian national lockdown. this can be interpreted as anxiety and concern in response to the quickly imposed stringent measures by the italian government in response to the outbreak of the virus in italy, which at this point was largely believed to be the epicentre of the pandemic. this was coupled with economic turmoil and great concern over the capacity of hospitals and their ability to handle the high requirement for intensive care units that would ensue . a similar pattern emerges in r f r , a sharp increase over the initial days of the french national lockdown period, afterwhich r f r continues to rise throughout the lockdown period at a lower and inconsistent rate. a similar story could be tailored to r es . whereas, the major increase in r de occurs fig. . u.k. rate of depression before and during the national lockdown. noise in the rate of depression has been smoothed with a -day moving average. in the build-up month, whilst during the german national lockdown, r de increases in the initial days, albeit at a lower rate. r de then plateaus and decreases -creating a turning point in r de during the german national lockdown. furthermore, we can observe the r of the respective countries following the easing of respective lockdowns and interpret them as the countries' outlook on the easing of restrictions. from the time period that we have available it seems that the french and spanish general populations experienced a reduction in symptoms of depression, such as anxiety, as is evidenced by the clear reduction in r f r and r es respectively. we can therefore conclude by, tentatively, stating that the easing of restrictions were received by an improvement in the mental state of the general populations of france and spain, the mental state of the italian and german general populations deteriorated, whilst the general mental state of the u.k. was rather agnostic to the easing of restriction. we are hesitant to state the changes in the rates of depression had been caused by the imposition/easing of national lockdowns. to make such a claim we would be required to undertake a more fine-grained causality study which is beyond the scope of this paper, however we note this for future work. we can however claim to have discovered clear relationships between the drastic changes in the behaviour of rates of depression during the periods of the build-up to, during and in the aftermath of national lockdowns v. conclusion our set of experiments have been conducted with the aim of providing organisations with a methodology for monitoring and analysing temporal mental health dynamics using social media data. we examine sample representations and their ability to impact classifier performance. we investigate the role of including an imbalanced dataset in the classifier training regime. our classifier provides encouraging performance on two fronts: the first being that it is able to discriminate with high certainty between clear diagnosed and control samples and secondly, it was able to identify the christmas depression phenomenon supported by the literature. finally, we present an analysis and discussion of the rates of depression and their relationships with key events during the covid- pandemic. we reiterate that through the analysis conducted in this paper, we cannot state that the measures imposed caused the changes in rates of depression during the pandemic and leave this causality analysis for future work. mental health monitoring methodologies such as the one proposed in this paper can be adopted by governments, to identify relationships between the general population's mental health state to imposed measures, mental health authorities, to assist in planning and targeting individual locations in which to dynamically concentrate their resources, as well corporations involved in producing or disseminating drugs, such as pharmaceuticals, to combat mental health issues for a more commercial use case. coronavirus: boris johnson announces uk government's plan to tackle virus spread, youtube impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand doctors: covid- pushing italian icus toward collapse understanding comorbidity with depression and anxiety disorders large-scale analysis of counselling conversations: an application of natural language processing to mental health could behavioral medicine lead the web data revolution? the language of depression the psychological functions of function words quantifying mental health signals in twitter predicting postpartum changes in behavior and mood via social media social media as a measurement tool of depression in populations predicting depression via social media bert: pre-training of deep bidirectional transformers for language understanding detecting depression and mental illness on social media: an integrative review anxiety and depression: comorbidity, psychopathology, and social functioning christmas depression long short-term memory adam: a method for stochastic optimization what are we depressed about when we talk about covid : mental health analysis on tweets using natural language processing a test collection for research on depression and language use the language of paranoia you are what you tweet: analyzing twitter for public health multi-kernel svm based depression recognition using social media data psychological aspects of natural language use: our words, ourselves the treatment of generalized anxiety disorder in patients with depressive symptomatology' risk factors and predictive signs of postpartum depression language use of depressed and depression vulnerable college students depression detection via harvesting social media: a multimodal dictionary learning solution the psychological meaning of words: liwc and computerized text analysis methods utilizing neural networks and linguistic metadata for early detection of depression indications in text sequences attention is all you need an account of a series of experiments, instituted with a view of ascertaining the most successful method of inoculating the small-pox detecting community depression dynamics due to covid- pandemic in australia france imposes -day lockdown and mobilises , police to enforce coronavirus restrictions france eases lockdown after eight weeks germany bans groups of more than two to curb virus germany says football can resume and shops reopen all of italy is in lockdown as coronavirus cases rise coronavirus: italy's pm outlines lockdown easing measures spain orders nationwide lockdown to battle coronavirus spain plans return to 'new normal' by end of coronavirus updates: 'you must stay at home' uk public told -bbc news uk past the peak of coronavirus, says pm purver is partially supported by the epsrc under grant ep/s / , and by the european unions horizon pro-gramme under grant agreements (saam, supporting active ageing through multimodal coaching) and (embeddia, cross-lingual embeddings for less-represented languages in european news media). the results of this publication reflect only the authors views and the commission is not responsible for any use that may be made of the information it contains. we express our thanks to all of our data annotators: l. achour, l. del zombo, n. fiore, m. hechler and r. medivil zamudio. key: cord- -yirpxgqi authors: ibáñez-vizoso, jesús e.; alberdi-páramo, Íñigo; díaz-marsá, marina title: international mental health perspectives on the novel coronavirus sars-cov- pandemic() date: - - journal: nan doi: . /j.rpsmen. . . sha: doc_id: cord_uid: yirpxgqi nan dear editor: different epidemics have taken place so far in the st century, caused by infectious diseases such as sars (severe acute respiratory syndrome) or mers (respiratory syndrome from the middle east). several studies have described an important psychological impact of these epidemics on the general population, patients, and health workers, proposing different measures to guarantee mental health and prevent the progression of psychopathology in these circumstances. , the emergence and rapid spread in wuhan, china, of the novel sars-cov- coronavirus led to unprecedented measures such as the lockdown of wuhan and millions of people in additional cities and provinces. the enormous psychosocial impact of these actions, together with the background described, fueled the rapid emergence in china of various psychological assistance services based on crisis intervention procedures. subsequently, different approaches in mental health have been promoted in countries such as south korea, japan and spain as the virus has spread internationally. , in late , the first cases of pneumonia of unknown cause were reported in wuhan. the sars-cov- coronavirus was soon identified as the causative agent of the covid- disease. it usually presents with fever, cough and dyspnea, presenting a mortality rate of approximately %. , on january , the who declared covid- as an epidemic and pheic (public health emergency of international concern). on march it was classified as a pandemic after its rapid international spread. the mental health effects of the new epidemic are mostly unknown. during the sars epidemic, the affected patients in a toronto hospital experienced fear, loneliness, anger, the psychological effects resulting from symptoms of infection and concern about quarantine and contagion. the fear of contagion stood out in the health workers. stigmatization affected both patients and professionals. among emergency staff in taiwan, . % had significant symptoms of post-traumatic stress syndrome. in the south korean mers epidemic, it was found that anxiety and anger symptoms predominated among isolated patients, especially in patients with a psychiatric history. these epidemics, caused by other coronaviruses, may offer clues about the possible effects on mental health of covid- in the general population, among patients and among health workers. among the general population, in a study carried out in china, more than half of the respondents reported a moderate---severe psychological impact, while . % and . % respectively reported moderate to severe depressive and anxious symptoms. it has been noted that among subjects suffering from mental illness, the impact could be even greater. , regarding patients diagnosed with covid- , it has been suggested that they may experience fear and distress from the potentially fatal consequences of infection and isolation. furthermore, the symptoms of infection and the adverse effects of treatment, such as insomnia caused by corticosteroids, could worsen anxiety and psychological distress. health workers face challenges such as healthcare overflow, the risk of infection, exposure to family grief, and ethical and moral dilemmas. , a study in china found among them a high prevalence of symptoms of depression, anxiety and insomnia ( . %, . % and . %, respectively). women, nurses, and the most exposed workers reported more symptoms. taken together, these data raise concern about the psychological well-being of the health personnel involved. the covid- pandemic has also required the quarantine of multiple subjects exposed to the infection, with uncertain effects on their mental health. in a recent review on the effect of quarantine of some epidemics of this century (sars, mers, a/h n flu and ebola), a higher prevalence of psychological distress, affective symptoms (low mood or irritability) and post-traumatic stress are described, some of which could be long-lasting. fear of contagion, lack of information, financial losses and stigma are some of the stressors associated with the quarantine, so measures are proposed aimed at improving communication or providing the necessary material means. some general principles have been established for the intervention with patients and health workers such as: (a) psychological support by multidisciplinary teams, with clinical screening for anxiety, depression and suicidality; https://doi.org/ . /j.rpsm. . . - /© sep y sepb. published by elsevier españa, s.l.u. all rights reserved. j o u r n a l p r e -p r o o f letter to the editor patients with psychiatric comorbidity should benefit from adequate follow-up; (b) accurate information to patients and health personnel; stay up to date and correct misinformation; (c) attention to symptoms such as insomnia as an early clinical marker; (d) efforts to overcome interpersonal isolation; (e) anticipate and counsel about stress reactions, teaching to recognize signs of distress and discussing strategies to reduce it. the responses of the majority of patients and health workers are adaptive to stress of this nature. , , furthermore, specific measures have been implemented in different places. in china, a national guideline of psychological crisis intervention was published for covid- . in wuhan, the most affected location, psychological intervention teams were organized, consisting of experts in psychological interventions, psychiatrists and psychological assistance hotline teams. this approach is proving effective and has been implemented in other hospitals. a free-access manual for psychological intervention and self-help was published in sichuan province, with detailed recommendations for different population groups (suspected patients, family members, doctors, etc.). -hour psychological assistance hotlines were also set up there, and an online survey on the mental health status of patients and medical workers was organized to collect information and offer recommendations based on the score. structured letter therapy has also been proposed in china for quarantined patients. in south korea, the national center for disaster trauma has distributed leaflets reporting alarm symptoms (somatic symptoms, insomnia, anxiety, poor concentration, etc.) that require evaluation by mental health professionals, and offer indications (contact with close friends, focus on reliable information, maintaining pleasant activities) for quarantined individuals. in japan, recent imperceptible-agent emergencies have increased fear associated with unseen agents such as infectious agents, and the spread of distress reactions or risky behaviors such as alcohol consumption is feared. it has been proposed to focus efforts on vulnerable populations: patients and their families, those of chinese origin, vulnerable populations due to their psychiatric background and health workers. as for spain, the rapid transmission of sars-cov- has prompted rapid setup by the psychiatry services of units for the psychological care of patients and health professionals, both face to face and by telephone. the spanish psychiatric society (sep) has released fact sheets for the general population describing common reactions to infectious epidemics, as well as tips for dealing with isolation and quarantine. likewise, it has issued recommendations to guarantee the mental health of health workers. regarding outpatient care for psychiatric patients, telemedicine encounters have been extended, for which there are apa (best practices in videoconferencing-based telemental health) guidelines updated in march . definitely, given the high psychosocial impact of the sars-cov- coronavirus pandemic, it is necessary to continue with the implementation and development of mental health services in the health response to covid- . the description of internationally adopted strategies can guide their application in different health contexts. mental health status of people isolated due to middle east respiratory syndrome wen soon s. psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china the mental health of medical workers in wuhan china dealing with the novel coronavirus mental health care measures in response to the novel coronavirus outbreak in korea public responses to the novel coronavirus ( -ncov) in japan: mental health consequences and target populations epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan china: a descriptive study timely mental health care for the novel coronavirus outbreak is urgently needed the immediate psychological and occupational impact of the sars outbreak in a teaching hospital the psychological effect of severe acute respiratory syndrome on emergency department staff coping with coronavirus: managing stress, fear, and anxiety patients with mental health disorders in the covid- epidemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease cuidando la salud mental del personal sanitario the psychological impact of quarantine and how to reduce it: rapid review of the evidence the psychiatric impact of the novel coronavirus outbreak caring for patient's mental well-being during coronavirus and other emerging infectious diseases: a guide for clinicians; csts fs caring for patients mental wellbeing during coronavirus psychological crisis interventions in sichuan province during the novel coronavirus outbreak a novel approach of consultation on novel coronavirus (covid- )-related psychological and mental problems: structured letter therapy cuide su salud mental durante la cuarentena por coronavirus the american psychiatric association and the american telemedicine association. best practices in videoconferencingbased telemental health páramo a,b , marina díaz-marsá a,b,c a instituto de psiquiatría y salud mental key: cord- -my wj uu authors: sheridan rains, luke; johnson, sonia; barnett, phoebe; steare, thomas; needle, justin j.; carr, sarah; lever taylor, billie; bentivegna, francesca; edbrooke-childs, julian; scott, hannah rachel; rees, jessica; shah, prisha; lomani, jo; chipp, beverley; barber, nick; dedat, zainab; oram, sian; morant, nicola; simpson, alan title: early impacts of the covid- pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses date: - - journal: soc psychiatry psychiatr epidemiol doi: . /s - - - sha: doc_id: cord_uid: my wj uu purpose: the covid- pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. we aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these. methods: we searched for relevant material in the public domain published before april , including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. search languages were english, french, german, italian, spanish, and mandarin chinese. relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach. results: we found eligible sources from countries. most documented observations and experiences rather than reporting research data. we found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. we summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future. conclusion: our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the covid- pandemic in several countries. we identify potential foci for service planning and research. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. they may be disproportionately negatively affected because the area already more likely to be experiencing social isolation and exclusion, stigma, and financial, employment and housing difficulties [ , ] . potential short-term impacts on people with pre-existing mental health conditions include: • effects of being infected with covid- , including any psychiatric sequelae, potentially increased risk of being infected or of severe covid- among some groups of people with mental health conditions, and concerns regarding equitable provision of physical healthcare. • effects on people with mental health problems resulting from infection control measures, including potential impacts of social isolation, and lack of access to usual supports, activities and community resources [ ] . • challenges associated with infection control in group settings, especially in hospitals and residential settings. • the effects of reduced or re-configured mental health care delivery. various adaptations and innovations to enable mental health services to respond to new requirements have been discussed, including infection control strategies on mental health service premises, and remote working [ , ] . while a number of position papers have been published, there has been relatively little systematic documentation of the impacts of the pandemic on people already living with mental health problems and on mental health care, and of strategies to mitigate these. these have been identified as urgent priority research areas [ , ] . we aim to begin addressing this by searching for and summarising relevant material in the public domain early in the pandemic, including accounts published by people with relevant lived experience, practitioners, mental health organisations and policy makers, and also by journalists who have investigated experiences and perspectives of service users, carers and service providers. our aim was to conduct a document analysis to create an initial mapping and synthesis of reports, from a number of perspectives, on the early impacts of and responses to the covid- pandemic on mental health care and people with mental health conditions. we drew on published sources of all types and included several languages used in countries in which the impact of the pandemic has been severe. we conducted a framework synthesis to summarise themes from sources reporting narratives and experiences of the impact of the pandemic and describing responses to it at both individual and service levels. we had planned, if warranted, also to conduct a narrative synthesis of any scientific data retrieved in our search: there was little as yet (table a) : this paper, therefore, primarily reports on our analysis of a wide range of documents in the public domain through a rapid qualitative framework synthesis method. specifically, we sought to analyse reports regarding: • direct impacts of covid- , subsequent public health measures and sudden social changes on people with preexisting mental health conditions and their families; • self-help and informal help strategies utilised by service users and carers; • challenges faced by mental health services during the pandemic; • innovations and adaptations to mitigate impacts of covid- on mental health services, and reports regarding their effectiveness. rapid syntheses are recommended by the world health organization as an appropriate and timely method in rapidly developing situations [ ] , quickly providing actionable evidence that can help inform health system responses. our protocol was prospectively registered on prospero (crd ). we took a multi-faceted approach to scope a broad, rapidly updating literature base and identify reports, articles and media from a wide range of perspectives and countries. the following database and 'grey' literature searches were conducted: the detailed terms used for database and web searches appear at the end of the supplementary report (supplementary report, section ). we included items meeting the following criteria: • population mental health services, people using any mental health services or who have mental health difficulties that appear to pre-date the pandemic, or mental health service staff. • phenomenon covid- . • focus relevant to at least one of the topics above, focusing on people already living with mental health conditions at the onset of the pandemic, or on mental health care. • source type published paper, article, blog post commentary, online media (including videos and podcasts), relevant to the research questions. social media were excluded, as were blogs and articles not published via a public media channel or on the website of a public body or charity. • date january -april . • language publications in english, french, spanish, german, italian or mandarin chinese. we selected these languages as we were able to involve native speakers and anticipated a substantial relevant literature. we excluded items focusing mainly on learning disability, autism or dementia, unless combined with comorbid mental health problems, and those mainly discussing staff wellbeing. queries were raised with the wider research team and discussed until consensus was reached. a senior reviewer (sj) checked a subset of articles to validate inclusion decisions. for each included item, title, author, website address, access date, source type (e.g. journal article, news report, video, guidance, etc.), country, setting, service user group, and author background(s) were extracted. framework-based synthesis was used to enable a systematic and structured approach to rapidly summarising and analysing a large dataset [ , ] . analysis comprised the following steps: three researchers (sj, lsr and ts) familiarised themselves with relevant materials of various types, and then developed an initial analytic framework, comprising questions related to our study topics. we developed a semi-structured data collection form using qualtrics software (qualtrics, provo, ut) to capture data from each article (supplementary report, section ). eight researchers piloted the form with five articles, and the framework was adjusted and finalised based on their coding and feedback. "other" and "research reflections" categories were included to allow capture of material not covered by the initial framework. included materials from the search were indexed and charted using the online form. to conduct this work rapidly in all included languages, a large number of researchers (n = ) were involved, most postgraduates, research staff or lived experience researchers linked to university college london or king's college london. examples of well-coded articles were provided, and the first articles coded were checked (by lsr, blt, and ts) to ensure consistency, with further training for individual researchers provided as necessary. these data were then imported into microsoft excel to create the framework matrix for mapping and interpretation. twelve researchers experienced in qualitative analysis (sj, ts, lsr, pb, jn, blt, fb, jec, hs, jr, ps, and sc) mapped, interpreted, and summarised the data. initially, a thematic framework was developed through discussion among them and with senior study researchers. each researcher was assigned a portion of the data (normally one or more themes) and asked to summarise all data in the framework matrix relevant to that theme into narrative and tabular summaries. they returned to original sources if summaries were unclear or very limited. these were then discussed, further synthesised and combined to produce the results below and in the supplementary report (section ). we found relevant sources, including articles from the published literature databases, from web searches focused on relevant organisations, and from search engines: sources are listed in the linked mendeley repository [ ] . non-english language articles were identified through translated searches. further articles were identified through expert recommendation and tweets. included articles were english (n = ), chinese (n = ), french (n = ), german (n = ), italian (n = ) and spanish (n = ). table summarises included article characteristics. detailed summaries for each theme are in our supplementary report (section ): here we provide an overview. we focus first on reports regarding impacts of the pandemic on people living with mental health problems and individual strategies for coping, then on impacts on the mental health care system and adaptations and innovations put in place. similar themes appeared to emerge across countries and types of source, so all are reported together. any peerreviewed papers reporting data are identified below; position papers, editorials and other work describing perspectives and experiences of scientists rather than data are synthesised along with other sources. most sources on this topic gave narratives and personal observations regarding deteriorating mental health (supplementary report, table ), but a handful of surveys had been conducted among people with mental health conditions (supplementary report, table a ). a survey of young people with mental health needs, and two surveys of adults with mental health problems, all carried out for uk mental health charities, found that around four out of five respondents described experiencing increased mental health difficulties following the onset of the pandemic [ ] [ ] [ ] . the survey of young people reported high levels of anxiety and impulses to self-harm in the week in which schools closed in england. a report from a survey focused on financial impacts elicited self-reports of poorer wellbeing in adults with mental illness being linked to current financial and employment concerns [ ] . a further survey carried out by an academic organisation and a charity again elicited many self-reports of worsened mental health very early in the pandemic [ ] . a usa research study in pre-print showed self-reports of worse mental health in the majority of adults with mental illnesses, with only approximately one in ten feeling that they were coping well with the situation [ ] . in a small published chinese study, hao and colleagues found that service users were experiencing more severe mental health symptoms than the general population at the peak of the crisis in china [ ] . we found no longitudinal surveys, and only the small chinese study included a control group. many sources reported observations from clinicians or self-reports of negative impacts on pre-existing mental health conditions. mechanisms suggested for this included increased anxiety and fear of illness and death directly related to covid- ; impacts of "lockdowns" and social distancing policies, especially of isolation; interactions between symptoms of mental health problems and current public events and concerns; impacts of loss of support from health and other services; and effects of increased social adversities, such as domestic abuse, family conflict or loss of employment. some accounts described impacts on specific mental health conditions, while others simply described an overall negative impact. some conditions have been the focus of numerous and detailed narratives. among people with depression and anxiety, sudden loss of the routines and activities that help people keep well, loneliness and isolation, and increases in health anxiety related to covid- are recurrently identified as exacerbating factors. many articles on obsessive compulsive disorder (ocd) described struggles with requirements for hygiene that contradict usual strategies for managing ocd and intensification of obsessional thoughts about contamination or infection. regarding people with eating disorders, we found many reports that loss of eating and social routines, disrupted access to food and the increased societal prominence of food seem to exacerbate some people's symptoms. one survey of service users with eating disorders found that % reported worsening of symptoms during the first weeks of lockdown in spain [ ] . negative impacts on mental health conditions were described alongside resilience in adversity and even some positive experiences of the pandemic period (see below). several scientific and media articles predicted a rise in suicide. however, an international collaboration of suicide experts argued this should not be accepted as an inevitability, but mitigated through urgent development of suicide prevention strategies [ ] . a few sources also described exacerbation of mental health problems as people replace usual coping strategies with more problematic ones, such as alcohol and substance use or gambling. the pandemic has resulted in extensive and sudden social changes and new risks, some with particular relevance to people living with mental health problems. we mapped the following themes: many sources described loneliness, social isolation and loss of usual activities, and the negative impacts of these on mental health. many people with mental health problems rely on the stability of routines and social contacts to manage their mental health condition, feel connected, and detect signs of deterioration. loneliness was described as arising both from general restrictions on activities and contacts, and from sudden closure of services, including therapeutic sessions and groups, which had been sources of highly valued contacts. patients in inpatient settings have been particularly affected by suspension of visits and leave, sometimes leading to extreme isolation and loneliness, especially when compounded by requirements to stay in hospital rooms and cancellation of ward activities. negative impacts from closure or restriction of a range of services were frequently discussed (see also below for discussion regarding service-level changes). some individuals reported abrupt termination or interruption of their treatment, or the replacement of face-to-face appointments by brief check-in phone calls. others reported being unable to access care for new difficulties, or the postponement of periods of psychological therapy that were about to begin. some sources described feeling abandoned, with a lack of access to information about how to seek urgent help if needed or about when care might resume. remote care was not always seen as sufficient, due to lack of access to or ability to use technology, lack of privacy to engage in remote appointments, and more superficial therapeutic contacts. interruption to medication access and adherence was also reported by several sources, including disruptions to supply or to in-person contacts required to prescribe, monitor side effects and toxicity, and administer medication. some sources reported deterioration in mental health in the context of cessation of medication or lack of monitoring or care. a common theme was that "we are not all in this together", with covid- risks magnifying existing inequalities and creating new ones [ ] . thus covid- and accompanying restrictions were seen by some sources as disproportionately affecting those already experiencing health and social inequalities, through economic impacts, the greater hardships of social restrictions in poor living circumstances, and the withdrawal or restriction of services disproportionately relied on by more deprived populations. withdrawal or reduction of services has been described as resulting in substantially more pressure for families and carers to support service users and manage distress and behavioural difficulties. some families with caring responsibilities have reported feeling abandoned by services, especially in the context of the stresses and greater isolation associated with the "lockdown". meanwhile, some service user accounts expressed worry about 'burdening' relatives by relying on them during the lockdown, or about risks of infecting relatives with covid- , particularly those at greater risk of severe illness. there were also some positive descriptions of enhanced relationships with family and friends during this period, especially by keeping in touch more online or by phone, and some had moved in with family and become closer as a result. a widely expressed concern regarding families shut in together related to the risk of increased conflict, aggression, and violence between household members and especially towards children: many sources expressed concern about this, while a smaller number described relevant incidents. concerns related to people with mental health problems both as victims and as perpetrators. the advice to "stay home" is challenging when home is not a safe space. both current household circumstances and reduced access to police, social services, schools and courts are identified as risk factors for continuing conflict and abuse. seeking help may be difficult if abusers are in constant proximity. sources argued that systems of care and outreach need to be provided for at-risk populations, potentially including communication of these via social media. we did not find sources on the extent of covid- infection among people with mental health problems, or whether rates of infection, or of severe consequences of infection, differ from the general population, nor were there many individual narratives regarding the experience of covid- infection among people with mental health problems. there were some accounts of outbreaks of infection in hospital and residential settings and of service problems that might contribute to these, for example in the usa, china and italy (see below regarding inpatient service challenges). many authors noted that co-morbidity between mental and physical health problems, and lifestyle factors (drug and alcohol use, obesity or, in the case of eating disorders, malnutrition), may result in potentially greater risk of infection and of severe consequences of infection. particular concerns were raised regarding people living in poor housing and confined, crowded, or chaotic environments, such as prisons, inpatient or residential settings, or the homeless mentally ill, as hygiene, infection control, and physical distancing practices are likely to be especially challenging. some reports relate to people with mental health problems experiencing "dual stigma" in terms of additional barriers to accessing physical healthcare: concerns related to quality of treatment for covid- infection in psychiatric hospitals are discussed below. while negative reports exceeded them, some positive aspects of life during the pandemic were described in first person accounts, and via clinicians. some people drew comfort from feeling that everyone was "in the same boat": that people were experiencing a "shared trauma" or that the rest of society was now experiencing similar challenges to the ones they faced day-to-day, such as social isolation or anxiety, and so have greater empathy. feelings of decreased marginalisation, greater acceptance by wider society, and increased levels of community and solidarity were reported. for others, the focus on the pandemic distracted them from their pre-existing conditions, with some reporting fewer symptoms. second, some described being able to mobilise existing reserves of resilience and coping skills during the pandemic, sometimes resulting in an increased confidence. finally, there were many reports of people taking advantage of innovations in remote and digital support and the increasingly widespread use of video calls for communication, support and social contact. these were particularly valued by people for whom difficulties such as physical mobility, social anxiety or paranoia impede face-to-face contacts. many publications describe strategies that people with preexisting mental health conditions have used to manage their mental health and social stresses during the pandemic. a pressing need for many has been to try to replace the activities, routines and contacts that usually support self-management. reported self-management strategies in the pandemic have included engaging in purposeful, creative or relaxing activities, such as cooking or painting, or keeping journals to record worries or positive experiences. use of therapeutic and self-help techniques, such as mindfulness, exposure therapy or meditation, was widely reported, though some found these of limited usefulness given current challenges. others have sometimes found helpful self-management tools and resources, including helplines, online therapy services, websites, podcasts and apps. the importance of maintaining a positive attitude, of selfacceptance and of not putting oneself under pressure was widely expressed. looking after one's physical health, such as taking regular exercise and healthy eating, maintaining a daily routine, and keeping in contact with trusted friends and family members, was emphasised in many sources. a number of people, particularly those with anxiety, reported attempting to avoid or substantially reduce their consumption of potentially stressful or triggering media coverage of the pandemic, relying instead on official or other trusted sources. several sources described types and impacts of practical and emotional support among peers. this included mutual support and practical help, such as collecting medication. sharing experiences and stories of mental health management, coping strategies and positive adaptations featured. digital and online approaches to delivering support had been proactively and creatively deployed in some peer networks to facilitate one-to-one, group and community connections and activities (including recreation and socialising). communicating and connecting were considered vital for reducing social isolation in lockdown, managing mental health, and maintaining relationships with friends, family and peer support networks. the importance of connecting with others in inpatient settings during the pandemic was also mentioned. mutual aid among peers appeared to have positive wellbeing benefits for those offering support. table ) reports based on official data were not generally available at this early stage, but several sources included reports from service managers and clinicians regarding service activity. most reported reduced referrals and presentations to community mental health services, emergency departments and psychiatric wards in the early phases of the pandemic, though one italian source described a subsequent rise. potential explanations included service users' fears of infection, beliefs that help would not be available, or wishes not to burden services. meanwhile, large increases were reported in several countries in use of relevant helplines and, in the usa, a rise in prescriptions for mental health medication. in inpatient settings and supported housing where people live together, immediate concerns were with preventing the spread of infection while attempting to maintain a therapeutic environment. regarding immediate infection control, clinicians' reports from several countries described a lack of protective equipment, an inability or unwillingness of some patients to adhere to protocols, and difficulties with distancing due to ward and office layouts. lack of realistic guidance specific to mental health settings was recurrently reported. lack of expertise or facilities to treat people with covid- effectively was identified as a challenge in providing equitable care, especially where pressure was reported to treat people with mental health problems and covid- as far as possible within psychiatric hospitals. a tension was frequently reported between providing good quality mental health care and infection control, with many inpatients confined to their rooms much of the time with limited face-to-face contacts and little access to advocacy, group-based therapeutic activity or trips into the community. the most frequently reported inpatient adaptation to meet these challenges was the creation of covid- specific units for psychiatric patients with confirmed or suspected illness, often with support from physical health care professionals and protocols in place for transfer to intensive care if needed. other infection control measures included quarantine following admission, early discharge and initiatives to reduce admissions, staggered mealtimes and reduced use of communal spaces. an innovation described by several sources was enhanced use of technology to enable remote contact with healthcare professionals for therapy during hospital admissions, and with families to maintain social contact. in some settings, depending on current national restrictions, group therapy sessions and external visits were maintained with use of personal protective equipment (ppe) and physical distancing protocols. although supported housing settings face some similar challenges to inpatient units, we found few reports about these. the predominant challenges reported in community settings were the need to reduce face-to-face contact and to cope with reduced capacity due to staff absence, diversion of resources to covid- wards, and reduced community resources in general. settings where service users mingle (e.g. day services) tended to have closed, and in some regions, for example of spain and italy, all but urgent response appeared to have closed at the onset of the pandemic, diverting resources to physical healthcare. however, a more usual response around the world appears to have been maintaining community service provision, but with much more restricted face-to-face contact. for the face-to-face working that has continued, poor access to ppe and lack of clear infection control procedures featured in reports from community mental health settings in several countries. telehealth tools appear to have been rapidly implemented in community mental health services across the globe, allowing care to continue at least to some extent. video calls are used both for staff meetings and patient contacts, with some innovative use for group and activity programmes. the use of digital tools such as apps and websites for therapy appears to have also increased, but was less discussed. this shift to telemedicine appears to be welcomed for use in some contexts by many clinicians and service users, who expect this to outlast the pandemic. however, important impediments and limitations were that some service users lacked technological access and expertise, or privacy for calls; poor technology resources in services; and potential negative impacts on rapport and therapeutic relationships. the voices of the digitally excluded are particularly likely to remain unheard. several challenges were identified in maintaining professional values and human rights during the pandemic. these especially-although not exclusively-centred on inpatient psychiatric settings. some sources, especially from france, argued that access to physical health care (for covid- ) is inequitable for mental health service users, and that they may receive poorer quality health care, due to stigma and to a policy of treating them as far as possible in psychiatric units rather than general hospitals. there were also concerns that mental health care may become less ethical during the pandemic, with clinicians and service users in various countries reporting beliefs that medication doses and the use of sedation have increased, or that coercive and restrictive practices which impact rights and freedoms may be rising, especially in wards with compromised therapeutic environments and access to advocates. though they have not as yet been put into practice, the provisions in the emergency coronavirus act in england and wales were reported to have caused great concern by potentially allowing involuntary admission decisions to involve fewer healthcare professionals, extending time limits on detention and facilitating the use of treatment without consent. reduced access to legal representation and advocacy was also reported. the final theme concerned fears and expectations about the future. internationally, a delayed wave of increased need for services was widely anticipated, potentially combined with reduced resources to meet this, especially where services are already underfunded. the potential long duration and fluctuating nature of the pandemic was also a concern: coping strategies may not be sustained at individual or service levels. we summarise here the first reports regarding the impact of the covid- pandemic from a wide variety of sources, mapping the impacts, concerns, experiences and responses at an early stage from a variety of perspectives and locations, focusing on recurrent themes. reports suggest that individuals with mental health problems have much to cope with: pandemic fears and circumstances interact with some symptoms; routines, contacts and activities that people have developed to manage their mental health have been shattered; and loneliness and social isolation are more prevalent. the risk that social adversities and existing inequalities may get worse is very concerning. while the current situation is new, these reports are congruent with findings of persisting negative psychological and socio-economic impacts arising from previous epidemics [ , , ] . however, the narratives we examined also caution against making assumptions about impacts, as responses to the pandemic clearly vary. many people with mental health problems are unfortunately used to isolation and adversity: this may result in resilience and abilities to manage challenges actively and to draw on peer and community support. initiatives that support them in this are potentially valuable. regarding service impacts, the immediate wave of increased activity predicted by some seems not to have occurred in the early weeks of the pandemic, or to have shifted to services such as helplines. however, a later surge of activity is widely expected. currently, some of the most pressing concerns relate to inpatient and residential care settings. in these environments, there are both specific and immediate challenges regarding infection control, with severe potential consequences for failure, and a pressing need to combine infection control with maintaining a therapeutic environment, safeguarding patient rights, and avoiding isolation in hospital. rapid research to investigate and compare strategies to address these challenges would be valuable. in the community, reports of telehealth having been swiftly adopted are striking given that implementation of innovations in health services is often observed to be slow [ ] : both clinician and service user responses suggest it may well endure after the pandemic. adoption of telehealth has previously been slow in many countries, despite evidence that it can be an effective, cost-effective and acceptable approach to reducing treatment gaps and improving access to mental health care for service users, especially where access is otherwise limited [ ] [ ] [ ] . we suggest that an urgent task now is to further co-produce, test and implement promising telepsychiatry initiatives so that they are as effective and acceptable as possible, drawing on already available guidance and evidence. [ ] . barriers need to be addressed, the most appropriate technologies identified, and both staff and service users supported in their use. meanwhile, the limitations of these technologies and the need to be selective in their use also need to be recognised, especially where continuing use following the pandemic is contemplated. a range of legal, regulatory, organisational and cultural challenges will also need to be addressed [ , ] . our search was wide ranging, achieving our aim of capturing many perspectives from many types of source and country: however, it will not have been comprehensive. we have compressed a large amount of material into a small space to ensure that it is useful (our supplementary report provides much more detail). although we encompass multiple countries and languages, our scope is not global, and most notably includes few reports from low-or middle-income countries. many of the sources were identified using web search engines. search results from these are influenced by factors such as time of day and ip address, limiting replicability and comprehensiveness. our english search strategy was more extensive than for other languages, especially because english-speaking experts contributed additional sources. people with experience of using mental health services and mental health clinicians were involved in many ways with this research, but day-to-day management was mainly by academic researchers not currently using or working in services. we adopted a rapid qualitative process for coding and summarising the data [ ] , not including substantial double coding: experienced researchers checked each coder's first summaries, and during the summarising process, we returned to sources where there was inconsistency or lack of clarity, but it is likely that ideas and themes were missed. our process was primarily deductive and based on a positivist paradigm, although discussions amongst team members with qualitative analysis experience, and use of narrative summaries, helped to retain the inductive spirit of qualitative analysis within a large and rapid analytic process. as yet, relevant scientific data are few. we have grouped together narratives and observations from all other types of sources on the basis that when scientists are reporting views, experiences and predictions rather than research findings, these are not necessarily more informative than the experiences of people trying to manage their own mental health problems or of clinicians trying to support them and to maintain services. journalists do not generally follow the same principles of objectivity as scientists, but in a rapidly evolving situation their investigations have the advantages of being quickly carried out and of often reporting on direct contacts with service users and/or clinicians. they may, however, tend to focus on more extreme situations, just as the people with lived experiences or clinicians who write about their experiences are unlikely to be representative. their swiftly written reports do, however, provide a rich and varied corpus of material through which we can understand the range of early experiences, responses, knowledge and practice among people with pre-existing conditions and in the services that they use. with this work, we have created an early map of impacts and responses from the covid- pandemic that identifies areas requiring service and policy response, and many potential areas for future investigation. we note, however, that the current crisis is evolving rapidly, and suggest that while some concerns are likely to be consistent, it will be essential to continue to review needs, challenges and the success of responses, as much is likely to change. this study assimilated international and grey literature written in several languages. despite the inclusion of a wide variety of sources, there is an absence of discrete minority group perspectives and sources focusing on the disproportionate impact of covid- on bame (black, asian and minority ethnic) groups in particular. the synthesis touches on the denial of liberties of people with mental health problems but research is yet to explore aspects of urgency and emotionality around this issue or the effects of this as a secondary response. deprivation of rights from a fear that people cannot adequately socially distance, reducing the number of clinicians required to admit people under the mental health act and inequalities of treatment for those with mental health problems who have covid is unacceptable and worthy of future scrutiny. safety relating to mental health environments was omitted. given the challenges of segregation without the unethical use of sedation and solitary confinement, attention should be directed towards ward design to minimise contagion. regarding people's ability to self-manage, it is unclear to what extent this can be framed as 'resilience' in circumstances with few other options, and what can be maintained without support. others may only opt to self-manage from fear of infection or concern about being burdensome to an overwhelmed nhs. reported satisfaction with virtual consultations naturally omits the voice of those unable to participate, and so conclusions should be viewed with caution. digital exclusion is real and complex. issues raised in the paper-a triple whammy of poorer service, loss of rights (both informal and state sanctioned e.g. coronavirus act) and the reduced access to advocacy or legal services also have an aggregate relationship. the complexity of this effect requires deeper qualitative research. going forward, it is vital to understand the long-term mental health consequences that pandemics have on different intersections of society. this is an independently written perspective from lived experience contributed by some of the co-authors with relevant experience. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/ . /. factors associated with mental health outcomes among health care workers exposed to coronavirus disease covid- : results of a national survey of united kingdom healthcare professionals' perceptions of current management strategy-a cross-sectional questionnaire 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long-term psychiatric morbidities among sars survivors review of key telepsychiatry outcomes the empirical evidence for telemedicine interventions in mental disorders a systematic review of the use of telepsychiatry in acute settings guidance on the introduction and use of video consultations during covid- : important lessons from qualitative research the use of telepsychiatry during covid- and beyond telepsychiatry and the coronavirus disease pandemic-current and future outcomes of the rapid virtualization of psychiatric care fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science rapid qualitative research methods during complex health emergencies: a systematic review of the literature luke sheridan rains · sonia johnson , · phoebe barnett · thomas steare · justin j. needle · sarah carr , · billie lever taylor · francesca bentivegna · julian edbrooke-childs · hannah rachel scott · jessica rees · prisha shah · jo lomani , · beverley chipp · nick barber · zainab dedat · sian oram · nicola morant · alan simpson , on behalf of the covid- mental health policy research unit group key: cord- -s hljz authors: kang, lijun; ma, simeng; chen, min; yang, jun; wang, ying; li, ruiting; yao, lihua; bai, hanping; cai, zhongxiang; xiang yang, bing; hu, shaohua; zhang, kerang; wang, gaohua; ma, ci; liu, zhongchun title: impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the novel coronavirus disease outbreak: a cross-sectional study date: - - journal: brain behav immun doi: . /j.bbi. . . sha: doc_id: cord_uid: s hljz the severe outbreak of novel coronavirus disease (covid- ), which was first reported in wuhan, would be expected to impact the mental health of local medical and nursing staff and thus lead them to seek help. however, those outcomes have yet to be established using epidemiological data. to explore the mental health status of medical and nursing staff and the efficacy, or lack thereof, of critically connecting psychological needs to receiving psychological care, we conducted a quantitative study. this is the first paper on the mental health of medical and nursing staff in wuhan. notably, among medical and nursing staff working in wuhan, . % had subthreshold mental health disturbances (mean phq- : . ), . % had mild disturbances (mean phq- : . ), . % had moderate disturbances (mean phq- : . ), and . % had severe disturbance (mean phq- : . ) in the immediate wake of the viral epidemic. the noted burden fell particularly heavily on young women. of all participants, . % had accessed psychological materials (such as books on mental health), . % had accessed psychological resources available through media (such as online push messages on mental health self-help coping methods), and . % had participated in counseling or psychotherapy. trends in levels of psychological distress and factors such as exposure to infected people and psychological assistance were identified. although staff accessed limited mental healthcare services, distressed staff nonetheless saw these services as important resources to alleviate acute mental health disturbances and improve their physical health perceptions. these findings emphasize the importance of being prepared to support frontline workers through mental health interventions at times of widespread crisis. in november , a novel coronavirus disease was first reported and then became widespread within wuhan, the capital city of hubei province of china (chan et al., ) . the disease rapidly psychological distress among medical staff appeared gradually: fear and anxiety appeared immediately and decreased in the early stages of the epidemic, but depression, psychophysiological symptoms and posttraumatic stress symptoms appeared later and lasted for a long time, leading to profound impacts (chong et al., ; wu et al., ) . being isolated, working in high-risk positions, and having contact with infected people are common causes of trauma (wu et al., ; maunder et al., ) . these factors may have impacted medical and nursing staff in wuhan, leading to mental health problems. the experience of medical staff responding to sars shows that the effects on medical staff members' mental health have not only shortterm but also long-term impacts and that the value of effective support and training is meaningful (maunder et al., ) . efficient and comprehensive actions should be taken in a timely fashion to protect the mental health of medical staff. the chinese government has made various efforts to reduce the pressure on medical and nursing staff in china, such as sending more medical and nursing staff to reduce work intensity, adopting strict infection control, providing personal protective equipment and offering practical guidance. based on previous responses to middle east respiratory syndrome (mers), medical staff tend to believe that such measures help protect their mental health (khalid et al., ) . in addition, to reduce the psychological damage of covid- among medical and nursing staff, mental health workers in wuhan are also taking action by establishing psychological intervention teams and providing a range of psychological services, including providing psychological brochures, counseling and psychotherapy (kang et al., ) . at the same time, television news and online media are also disseminating information about coping strategies for psychological self-help. however, evidence-based mental health services are preferable, and it is necessary to assess the quality of mental health services (aarons et al., ) . therefore, we explore the mental health status of medical and nursing staff in wuhan, the efficacy of the psychological care accessed, and their psychological care needs. we recruited doctors or nurses working in wuhan to participate in this survey from january , , to february , . this study was approved by the clinical research ethics committee of renmin hospital of wuhan university (wdry -k ). data were collected through wenjuanxing (www.wjx.cn) with an anonymous, selfrated questionnaire that was distributed to all workstations over the internet. all subjects provided informed consent electronically prior to registration. the informed consent page presented two options (yes/ no). only subjects who chose yes were taken to the questionnaire page, and subjects could quit the process at any time. the questionnaire consists of six parts: basic demographic data, mental health assessment, risks of direct and indirect exposure to covid- , mental healthcare services accessed, psychological needs, and self-perceived health status compared to that before the covid- outbreak. basic demographic data include occupation (doctor or nurse), gender (male or female), age (years), marital status (unmarried, married or divorced), educational level (undergraduate or lower, postgraduate or higher), technical title (primary, intermediate, or senior), and department (divided into high-exposure departments and non-highexposure departments according to the possibility of exposure to confirmed patients; high-exposure departments included the fever clinic, emergency department, general isolation ward, and intensive care unit). we used four scales to assess the mental health status of medical and nursing staff. the -item patient health questionnaire (phq- ), the item generalized anxiety disorder (gad- ), the -item insomnia severity index (isi) and the -item impact of event scale-revised (ies-r) were used to evaluate depression, anxiety, insomnia and distress, respectively. the phq- is a self-report measure used to assess the severity of depression, with the total scores categorized as follows: minimal/no depression ( - ), mild depression ( - ), moderate depression ( - ) , or severe depression ( - ) (kocalevent et al., ) . the gad- is a self-rated scale to evaluate the severity of anxiety and has good reliability and validity. the total scores are categorized as follows: minimal/no anxiety ( - ), mild anxiety ( - ), moderate anxiety ( - ), or severe anxiety ( - ) (löwe et al., ) . the isi is a measure of insomnia severity that has been shown to be valid and reliable. the total scores are categorized as follows: normal ( - ), subthreshold ( - ), moderate insomnia ( - ), or severe insomnia ( - ) (morin et al., ) . the ies-r is a self-report measure used to assess the response to a specific stressful life event and has extensive reliability and validity. the event used for this questionnaire was the occurrence of covid- . the total scores are categorized as follows: subclinical ( - ), mild distress ( - ), moderate distress ( - ), and severe distress ( - ) (daniel and weiss, ) . exposure to covid- was determined with the following questions asked to medical and nursing staff: have you been diagnosed with covid- ? do you manage patients diagnosed with covid- ? has your family been diagnosed with covid- ? have your friends been diagnosed? have your neighbors (people living in the same community who may or may not know each other) been diagnosed? then, participants were asked whether there was anyone living with them with suspected symptoms. the answer to each question was yes or no. the following question was used to determine which psychological services the subject had accessed. have you ever received the following services: psychological materials (leaflets, brochures and books provided by mental health workers and distributed to staff in the hospital), psychological resources available through media (psychological assistance methods and techniques provided by psychologists through online media or tv news or various online platforms) (supplementary material), and counseling or psychotherapy (including individual or group therapy)? three areas were assessed regarding the psychological services that participants hoped to receive in the future: what kind of mental health service content were participants most interested in (including knowledge of psychology, ways to alleviate their own psychological reactions, ways to help others alleviate their psychological reactions, or ways to seek help from psychologists or psychiatrists); what kind of resources were most anticipated (including psychological materials, psychological resources available through media, group psychotherapy, individual counseling and psychotherapy, uninterested or other); and who participants would prefer to receive care from (including psychologists or psychiatrists, family or relatives, friends or colleagues, do not need help, or other). health status was determined by asking participants to compare their current health status to their health status before the outbreak of covid- : how do you perceive your current health status compared to your health status before the outbreak? (answer options included l. kang, et al. brain, behavior, and immunity xxx (xxxx) xxx-xxx getting better, almost unchanged, worse, or much worse). data analysis was performed using ibm spss statistics for windows (version . ) and mplus (version . ). descriptive analysis was used to describe the general data and currently accessed psychological services. for count data, frequencies and percentages were used. the k-means clustering method was used to cluster the phq- , gad- , isi, and ies-r scores (ball, ) . with the euclidean square root distance as the measurement index, the patients were divided into groups by the ward method. according to this grouping, exposure to covid- and the current state of mental healthcare services were compared. the chisquare test was used to compare the data for different categorical variables. a structural equation model (sem) was constructed via mplus to explore the relationship among the four components, namely, exposure, accessed mental healthcare services, mental health status (phq- , gad- , isi, and ies-r scores) and self-perceived health status compared to that before the covid- outbreak. the estimation method used weighted least squares with mean and variance adjustment test statistics (distefano and morgan, ) . we used a monte carlo method with guided resamplings to construct a confidence interval for the estimation effect (bauer et al., ) . in sem, several criteria, such as root mean square error of approximation (rmsea) values < . and comparative fit index (cfi) and tucker-lewis index (tli) values > . , indicate acceptable models (hu and bentler, ) . p values < . indicated that a difference was statistically significant. in total, participants, including ( . %) doctors and ( . %) nurses, completed the survey. a total of . % worked in highrisk departments. the participants tended to be female ( . %), be aged to years ( . %), be married ( . %), have an educational level of undergraduate or less ( %), and have a junior technical title ( . %), as shown in table . of all participants, . % had received psychological materials, . % had obtained psychological resources available through media, and . % had participated in group psychological counseling, as shown in table . according to the phq- , gad- , isi, and ies-r scores, the participants were divided into groups. thirty-six percent of the medical staff had subthreshold mental health disturbances (mean phq- : . , gad- : . , isi: . , ies-r: . ), . % had mild disturbances (mean phq- : . , gad- : . , isi: . , ies-r: . ), . % had moderate disturbances (mean phq- : . , gad- : . , isi: . , ies-r: . ), and . % had severe disturbances (mean phq- : . , gad- : . , isi: . , ies-r: . ). there were significant differences in the phq- , gad- , isi, and ies-r scores among the four groups, as shown in table . in contrast, there were no significant differences in demographic data among the four groups, as shown in table . for medical and nursing staff, exposure to people around them who were infected varied among the different groups. the group with subthreshold mental health disturbances had contact with fewer people confirmed or suspected to be infected with the virus. each group with a higher level of distress had a more extensive scope of exposure. there were also significant differences in mental healthcare services among the four groups; those with severe disturbances had accessed fewer psychological materials and psychological resources available through media. in addition, the perception of current health status compared to that before the outbreak of covid- was also different among the groups, as shown in table . we established an sem of the associations between the four areas. first, exposure as a risk factor for mental health, including the confirmed diagnosis of patients, the participants' themselves, family, friends, colleagues, neighbors, and coresidents with suspected symptoms, was analyzed in the previous step. second, the mental healthcare services accessed consisted of psychological materials and psychological resources available through media. third, mental health consisted of the phq- , gad- , isi, and ies-r scores. the fourth area was the subjective feelings of the staff regarding whether their physical conditions were worse than before the epidemic. the chi-square test of model fit yielded a value of . , with degrees of freedom = , pvalue = . , rmsea = . , cfi = . , and tli = . , indicating a good fit. the results showed that the risk factors of exposure affected mental health and that mental health affected subjective physical health perceptions. mental healthcare services only partially l. kang, et al. brain, behavior, and immunity xxx (xxxx) xxx-xxx mediated the relationship between exposure risks and mental health. mental healthcare services regulated the relationship between the risk of exposure and subjective physical health perceptions by affecting mental health. the results are shown in fig. and table . . . psychological care needs of medical and nursing staff in terms of the content of interest, namely, psychological care, medical and nursing staff with subthreshold disturbances most wanted to obtain skills to help alleviate others' psychological distress, whereas other medical and nursing staff most wanted to obtain self-help skills. medical and nursing staff with higher levels of mental health problems were more interested in skills for self-rescue and showed more urgent desires to seek help from psychotherapists and psychiatrists. medical and nursing staff differed in terms of how they wanted to obtain services based on their levels of mental health problems. medical and nursing staff with subthreshold and mild disturbances preferred to obtain such services from media sources, while staff with heavier burdens wanted to seek services directly from professionals. apart from medical and nursing staff with subthreshold disturbances who did not think they needed help from others, the other workers saw a greater need to obtain help from professionals than from close family and friends. the results are shown in table . this is the first mental health investigation in the wake of the coronavirus epidemic in wuhan, china that aims, in part, to explore the demand for mental healthcare services in this context. when cities are struck by deadly, large-scale disasters of various types, the characteristics of mental health problems that arise can differ across different periods (shioyama et al., ) . we therefore chose to survey a set of people (health care providers) in the discrete window of time soon after the initiation of a chaotic event (the outbreak of coronavirus infections). to conduct a comprehensive analysis, we used multiple different scales to evaluate the mental health of medical staff. our study has revealed the limits in the availability of mental healthcare services provided by psychologists and psychiatrists and thus the limits in access points for psychological care for distressed individuals, including less personalized sources of support such as publication-style psychological materials and psychological resources available from media. these latter methods can nonetheless contribute positively to alleviating mental health problems and physical discomfort caused by risk factors such as the exposure of close contacts to covid- . such exposure is known to be mentally injurious in epidemic settings: when the sars epidemic hit, not only did the direct exposure of the work environment affect the mental health of medical staff, but the infection of friends or close relatives generated psychological trauma (wu et al., ) . we found that subthreshold and mild mental health disturbances accounted for a large proportion of disturbances. people with such levels of disturbances may be more likely than those with more severe disturbances to take action and be motivated to learn the necessary skills and to adapt in productive ways to respond to diverse challenges. these skills have been shown in previous retrospective studies to be protective for later mental health (maunder et al., ) . in addition, we note that people with subthreshold and mild mental health disturbances want to find ways to better help others, which is beneficial for health care teams. in terms of physiology, positive coping has been seen to increase immune function when victimized subjects report high mental demands, leading to a better state of response (sakami et al., ) . however, there are negative consequences of stimulation caused by pressure, as acute psychological stress is known to activate the sympathetic adrenal medulla system and hypothalamus-pituitary adrenal axis, and this two-component stress response impacts physical and mental health and has disease consequences (turner et al., ) . in summary, continuous mental healthcare services are necessary even for subthreshold and mild psychological reactions during this epidemic to attenuate the possibility of escalating complications. multiple features were found for the group of untreated clinical l. kang, et al. brain, behavior, and immunity xxx (xxxx) fig. . in this model, the solid line represents a significant relationship between the two, while the dotted line represents the relationship is not significant. kang, et al. brain, behavior, and immunity xxx (xxxx) xxx-xxx personnel who had serious psychological problems. first, compared to less severely affected groups, they had accessed fewer printed psychological advice materials (e.g., office brochures) and had accessed less psychological guidance publicized through digital media. second, they were more likely to desire personalized, one-on-one counseling as a therapy option. one might speculate a cause-and-effect relationship wherein more frequent exposure of the other groups to the noted materials in some way protected them from reaching the most severely impacted category, but our cross-sectional results are, by nature, correlational. this study limitation does not detract, however, from the importance of widely implementing prevention and monitoring strategies; mildly to moderately impacted personnel expressed interest in having access to psychological guidance materials, which provides evidence of the importance of prevention strategies. the number of people suffering from mental health impacts after a major event is often greater than the number of people who are physically injured, and mental health effects may last longer. nonetheless, mental health attracts far fewer personnel for planning and resources (allsopp et al., ) . thus, the lancet global mental health commission's observation that the use of nonprofessionals and digital technologies can provide a range of mental health interventions may indicate an opportunity (patel et al., ) . our data are consistent with a model in which psychological advice and guidance in print resources and disseminated in the media can provide a level of protection for medical and nursing staff, improving mental health by reducing the stress impacts caused by high risk of infection. clearly, there is a role, nonetheless, for therapist-driven sessions, as previous research showed that a convenient group course intervention for doctors reduced depersonalization, improved views on the meaning of work, and achieved sustained results (west et al., ) . we anticipate similar benefit for covid- staff in wuhan based on our findings contained herein. interestingly, previous studies on medical staff and other infectious agents have repeatedly emphasized that mental health impacts are related to department and occupation (hawryluck et al., ; wu et al., ) . health care workers with professional knowledge about differences in the relative exposure patterns and transmission of different infectious diseases could gain some degree of comfort and control over their situations (chowell et al., ) . for example, over the decades, although hepatitis viruses and hiv have often caused lethal infections, radiologists, pathologists and nurses knew that their risk of exposure was low as long as they exercised caution in their contact with bodily fluids. the situation has been different in wuhan due to the pernicious characteristics of covid- . many infected individuals exhibit minimal or no symptoms while contagious, for example, early in the course of infection (bai et al., ) . these individuals may thus visit a variety of different hospital departments in an infectious but asymptomatic state, unknowingly spreading the disease directly through aerosolized droplets or indirectly through skin contact with handled surfaces. these features of the infectivity of coronavirus involve a substantial risk of exposure for medical workers, regardless of their hospital department, job title or building location; thus, any workerwhether doctor or nurse, specialist or generalistis at substantial risk. the resultant stress due to concerns about infection risk thus indiscriminately affects large numbers of personnel. there is a need to better recognize mental health needs as an important component of mobilizing a large-scale therapeutic response to sudden city-scale crisis scenarios. a large rapid response team in crisis situations should include mental healthcare workers. local medical and nursing staff at the epicenter of a crisis are pivotal to the overall response, and care for these caregiverswhether through face-to-face counseling or comparable support through digital platforms such as cell phone interfacesis essential in efforts to extend their immediate efficiency and to better protect their mental health in the long term. our research also has some limitations. first, compared with faceto-face interviews, self-reporting has certain limitations. second, the study is cross-sectional and does not track the efficacy of psychological services. due to changes in posttraumatic mental health, dynamic observation is necessary. a randomized prospective study could better determine correlation and causation. third, a larger sample size is needed to verify the results. in summary, the results demonstrate that a strikingly large portion of health care providers in virus-plagued wuhan are suffering from mental health disturbances. they would benefit from greater availability of personalized mental health care from psychotherapists and psychiatrists, wherein different mental health groups could focus on providing specialized mental healthcare services. among the steps needed to better prepare for future infectious disease outbreaks would be a greater investment in the mental health tools in society's medical arsenal to protect and care for future medical and nursing staff who find themselves unexpectedly on the dangerous front lines of disease response. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work 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of school children after the great hanshin-awaji earthquake: ii. longitudinal analysis psychological stress reactivity and future health and disease outcomes: a systematic review of prospective evidence intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial second-meeting-of-the-international-health-regulations-( )-emergency-committee-regarding-the-outbreak the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk this work was supported by grants from the national key r&d program of china (grant numbers: yfc ) and the national natural science foundation of china (grant numbers: ). wrote and contributed to the writing of the manuscript: zl, cm, lk and sm. supplementary data to this article can be found online at https:// doi.org/ . /j.bbi. . . . key: cord- - p ppawn authors: winhusen, theresa; walley, alexander; fanucchi, laura c.; hunt, tim; lyons, mike; lofwall, michelle; brown, jennifer l.; freeman, patricia r.; nunes, edward; beers, donna; saitz, richard; stambaugh, leyla; oga, emmanuel; herron, nicole; baker, trevor; cook, christopher d.; roberts, monica f.; alford, daniel p.; starrels, joanna l.; chandler, redonna title: the opioid-overdose reduction continuum of care approach (orcca): evidence-based practices in the healing communities study date: - - journal: drug alcohol depend doi: . /j.drugalcdep. . sha: doc_id: cord_uid: p ppawn background: the number of opioid-involved overdose deaths in the united states remains a national crisis. the healing communities study (hcs) will test whether communities that heal (cth), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = ), relative to wait-list communities (n = ), from four states. the cth intervention seeks to facilitate widespread implementation of three evidence-based practices (ebps) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (oend), effective delivery of medication for opioid use disorder (moud), and safer opioid analgesic prescribing. a key challenge was delineating an ebp implementation approach useful for all hcs communities. methods: a workgroup composed of ebp experts from hcs research sites used literature reviews and expert consensus to: ) compile strategies and associated resources for implementing ebps primarily targeting individuals and older; and ) determine allowable community flexibility in ebp implementation. the workgroup developed the opioid-overdose reduction continuum of care approach (orcca) to organize ebp strategies and resources to facilitate ebp implementation. conclusions: the orcca includes required and recommended ebp strategies, priority populations, and community settings. each ebp has a “menu” of strategies from which communities can select and implement with a minimum of five strategies required: one for oend, three for moud, and one for prescription opioid safety. identification and engagement of high-risk populations in oend and moud is an orccarequirement. to ensure cth has community-wide impact, implementation of at least one ebp strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in hcs-facilitated ebp implementation. in order to promote oend, effective delivery of moud, and safer opioid prescribing the study team developed an approach to ebp implementation with utility for all participating communities, which vary widely in their current ebp implementation, access to resources including needed workforce, and perceived acceptability of various ebps. this paper describes the framework developed to guide ebp selection and implementation strategies contained in the opioid-overdose reduction continuum of care approach. for each ebp component of the cth intervention, a workgroup consisting of ebp experts from each research site was established to develop an approach that would include standardization requirements across communities, while also providing enough flexibility to meet the varying needs of the hcs communities. a significant reduction in opioid-involved overdose deaths will require widespread implementation of oend, effective delivery of moud, and prescription opioid safety efforts. therefore, effective implementation of strategies for each of these three ebps is an hcs goal. the first task undertaken by this workgroup was developing a framework for organizing the targeted ebps and potential strategies for their implementation. the opioid-overdose reduction continuum of care approach (orcca), shown in figure , was adapted from the cascades of care for oud developed by williams and colleagues . cascades of care emphasizes four domains: prevention, identification, treatment, and remission. the orcca places greater emphasis on the hcs-goal of implementing ebp strategies that will reduce opioid-involved overdose fatalities and demonstrates how overdose reduction strategies overlap across a continuum of care rather than being discrete steps. the workgroup then developed the orcca's required elements and a companion technical assistance guide referencing existing resources to assist communities with implementation. based on research literature and expert consensus, the orcca includes required and recommended community settings, priority populations, ebps, and implementation strategies. in order to ensure the cth intervention has impact across multiple sectors interacting with individuals at high risk for an opioid-involved overdose and across the care continuum, each community is required to implement at least one of the ebps within each of three community settings: j o u r n a l p r e -p r o o f ) healthcare; ) behavioral health; and ) criminal justice. healthcare settings include outpatient healthcare centers, pre-hospital providers, emergency departments and urgent care, hospitals, primary care settings, and pharmacies. behavioral health includes substance use disorder and mental health treatment centers and social service agencies. criminal justice includes pre-trial, jails, probation, parole, drug and problem-solving courts, police and "narcotics" task forces, halfway houses, community-based correctional facilities, and department of youth services. communities provide a rationale for not engaging all three community settings. most people with oud in the u.s. are not enrolled in effective treatment . any individual misusing opioids or with oud is at risk for opioid-involved overdose death, particularly if not engaged in moud. a substantial proportion of people who die from opioid-involved overdose have had no interaction with the healthcare system in the previous year (larochelle et al., ) . thus, reducing overdose deaths will require engaging people who currently are not accessing overdose prevention or oud treatment services. this reality is the justification for an orcca requirement to identify and intervene with high-risk populations. individuals who are at highest risk for overdose, such as those who have overdosed or those who recently were treated in a withdrawal management program (colloquially referred to as "detox"), do not typically access moud (larochelle et al., ; walley et al., ) . specific factors that further elevate the risk of overdose among those using opioids include: ) having had a prior opioid overdose (caudarella et al., ; darke et al., ; larochelle et al., ; larochelle et al., ; winhusen et al., ) ; ) having reduced opioid tolerance (e.g., completing medically supervised or "socially" managed withdrawal, or release from an institutional setting such as jail, residential treatment, hospital) (binswanger, ingrid a. et al., ; larochelle et al., ; merrall, e. l. c. et al., ; strang et al., ; walley et al., ) ; ) using other substances (e.g., alcohol, benzodiazepines, stimulants) (brugal et al., ; cho et al., ; gladden et al., ; larochelle et al., ; park et al., ; sun et al., ) ; ) having a concomitant major mental illness (e.g., major depression, bipolar disorder, schizophrenia, anxiety disorders) (o'driscoll et al., ; pabayo et al., ; tobin and latkin, ; wines et al., ) ; ) having a concomitant major medical illness (e.g., cirrhosis, chronic kidney disease, copd, asthma, sleep apnea, congestive heart failure; infections related to j o u r n a l p r e -p r o o f drug use) (bosilkovska et al., ; green et al., ; jolley et al., ; larochelle et al., ; vu et al., ) ; and/or ) injecting drugs (bazazi et al., ; brugal et al., ) . in developing the orcca, the workgroup delineated three approaches to identifying high risk populations (see table ). these approaches include: ) identification within criminal justice settings and venues where high-risk populations seek services malta et al., ; park-lee et al., ; suffoletto and zeigler, ; weiner et al., ) , ) field-based outreach including point-of-contact for emergency response (bagley, s. m. et al., ; waye et al., ) , and ) the use of surveillance or other existing data sources to locate individuals likely needing intervention (formica et al., ; merrick et al., ) . in the first approach, ebps are incorporated into services at venues where people at high-risk may be present. the second approach includes real-time community outreach to high-risk venues and individuals. the third approach includes identifying newly emerging risk groups utilizing overdose surveillance data. in addition to defining populations at high risk for overdose, the orcca also identifies populations that would likely warrant tailoring ebp strategy implementation. these groups include adolescents (bagley et al., ; chatterjee et al., ; lyons et al., ) , pregnant and post-partum women (goldman-mellor and margerison, ; nielsen et al., ) , homeless populations (bartholomew et al., ; doran et al., ; magwood et al., ) , rural populations without transportation (arcury et al., ; bunting et al., ) and other factors related to poverty (snider et al., ; song, ), veterans (lin et al., mudumbai et al., ) , non-english speaking and immigrant populations (salas-wright et al., ; singhal et al., ) , racial and ethnic minorities (barocas et al., ; lippold et al., ) , people with mental health disorders (turner and liang, ) and mental/physical disabilities (burch et al., ; west et al., ) , people involved in transactional sex (goldenberg et al., ; marchand et al., ) , and people who have chronic pain (bohnert et al., ; dunn et al., ; james et al., ) . as one of the hcs requirements, communities will record the high-risk populations and community venues included in the selected ebp strategies. j o u r n a l p r e -p r o o f subgroups were established for each of the three ebps to assemble strategies and resources contained in the orcca. these subgroups created a forum for networking and collaboration among investigators with specific content expertise. subgroups drafted each respective menu (oend, moud, and safer opioid prescribing) and their technical assistance guide subsections. based on the likelihood of overdose reduction, the subgroups made recommendations on which strategies should be required and which should be optional. for example, the oend subgroup recommended that "active" distribution of oend be required, because it was concluded that reducing overdose on a community level required oend being pro-actively provided to high-risk populations. it would not be enough to "passively" make it available regardless of overdose risk. each subgroup reviewed the literature and completed online searches (e.g., samhsa website) for resources and toolkits. upon completion of each subgroup's section, the full workgroup convened to vote and approve the orcca. naloxone reverses an opioid overdose if administered quickly. overdose prevention education and broad community access to naloxone is associated with reduced opioid-involved overdose death (bird et al., ; clark et al., ; giglio et al., ; mcdonald and strang, ; walley et al., b) . oend includes clear, direct messages about how to prevent opioid overdose and rescue a person who is overdosing to empower trainees to respond to overdoses. oend can be successfully implemented at multiple venues among diverse populations. the oend menu (see table ) includes three sub-menus: a) active oend, which is required; b) passive oend, which is optional; and c) naloxone administration, which is optional. the following sections describe the rationale and evidence for the oend submenus. a) active oend active oend is proactive and targeted towards high-risk populations and their social networks or venues where high risk populations are likely to be found. active oend is a required orcca menu element because the best evidence for reducing overdose via oend has been shown among communities that pro-actively make oend accessible to those at high risk for overdose (walley et al., b) including people released from j o u r n a l p r e -p r o o f incarceration (bird et al., ) , and people with chronic pain treated with chronic opioid therapy through community health centers (coffin et al., ) . opioid overdose education typically includes education about overdose risk factors and how to recognize and respond to an overdose, including naloxone administration; training can be provided in a variety of formats including in-person or on-line. active oend examples include: syringe service program workers providing oend to people who inject opioids (doe-simkins et al., ; walley et al., b; wheeler et al., ) ; emergency department staff providing oend to patients seen for opioid-use complications (dwyer et al., ; gunn et al., ) ; and equipping people released from incarceration with naloxone (bird et al., ; wenger et al., ) . passive oend increases oend access to individuals referred by other providers and those seeking oend on their own and makes naloxone available for immediate use in overdose hotspots. as an optional orcca submenu, passive oend strategies are encouraged but not required because their impact is unlikely to be adequate to reduce overdose deaths compared to active oend strategies. examples of passive oend include distributing naloxone at a community meeting or making naloxone available at a pharmacy without a prescription pollini et al., ; sohn et al., ) , for example through pharmacy standing orders (abouk et al., ; davis and carr, ; evoy et al., ; xu et al., ) . this submenu also includes publicly available naloxone for emergency use where overdoses commonly occur, such as public restrooms (capraro and rebola, ) . the naloxone administration submenu focuses on increasing capacity for opioid overdose response and rescue by first responders such as police (wagner et al., ) and fire and emergency medical technicians (davis et al., ; davis et al., a; davis et al., b; rando et al., ) . in these programs, first responders are trained in overdose response and equipped with naloxone, so they have the capacity to administer naloxone when called. they do not distribute naloxone to others in the community. this is also an optional menu item because the impact is unlikely to be adequate to reduce overdose deaths compared to active oend. . . effective delivery of moud, including agonist / partial agonist medication j o u r n a l p r e -p r o o f moud decreases the risk of opioid-involved death (larochelle et al., ; pearce et al., ; sordo et al., ) but is widely underutilized (volkow and wargo, ; williams et al., ) . barriers to improved moud utilization include inadequate treatment availability, failure to identify and engage high-risk populations in moud, and poor treatment retention (morgan et al., ; samples et al., ) . accordingly, the moud menu (table ) is composed of three sub-menus: a) expand moud treatment availability; b) interventions to link people in need to moud; and c) moud engagement and retention. it is required that communities choose at least one strategy from each of the three moud submenus. evidence for decreasing mortality is strongest for methadone and buprenorphine. therefore, communities are required to choose strategies that expand access to, and improve retention in, treatment with these medications. strategies that focus on naltrexone are optional since this medication has less evidence for reducing opioid-involved overdose (larochelle et al., ) , although clinical trials suggest extended-release injection naltrexone can be effective for relapse prevention if adherence is secured (lee et al., ; lee et al., ; tanum et al., ) . the following sections describe the rationale and evidence for the three required submenus within the moud menu. communities must select at least one strategy that expands moud treatment availability with buprenorphine or methadone from this submenu. though each potential strategy includes multiple venues, the orcca does not prescribe which venues must be included outside of the overall requirement that communities choose at least one strategy that addresses healthcare, behavioral health, and criminal justice settings across all three main menus. the first submenu strategy is adding and/or expanding moud treatment in primary care, other general medical and mental health settings and substance use disorder treatment and recovery programs. historically in the us, addiction treatment has been isolated from general medical and mental health care settings, and moud treatment has been omitted from the care provided in primary care, hospitals (fanucchi and lofwall, ; jicha et al., ) , emergency departments (hawk et al., ) , and general mental health (novak et al., ) . furthermore, according to data from the national survey of substance abuse treatment facilities, many substance use disorder treatment programs do not provide moud (substance abuse and mental health services administration, c). specifically, in , the proportion of facilities offering buprenorphine, methadone, and j o u r n a l p r e -p r o o f long-acting naltrexone treatment was %, %, and % respectively (substance abuse and mental health services administration, c). moud treatment can be successfully integrated in these settings, increasing capacity and reducing treatment barriers (blanco and volkow, ; chou, r et al., ; korthuis et al., ) . the second submenu strategy is adding and/or expanding moud treatment in criminal justice settings. despite the strong evidence base, moud is not commonly provided in criminal justice settings, with only out of , us prisons and jails offering methadone or buprenorphine in (substance abuse and mental health services administration, e). incarceration is associated with increased risk of overdose death postrelease largely due to loss of tolerance after forced withdrawal during incarceration (binswanger et al., ; merrall, e. l. c. et al., ) . improving availability of moud in criminal justice settings, including pre-trial, jail, prison, probation, and parole, is a critical opportunity to reduce opioidinvolved overdose deaths (moore et al., ). the third submenu strategy is expanding access to moud treatment through telemedicine, interim buprenorphine (sigmon et al., ) , interim methadone (newman, ; schwartz et al., ) , or medication units (office of the federal register and government publishing office, b). expanding access to moud through telemedicine is especially salient as communities consider orcca strategies during the covid- pandemic. telemedicine models for buprenorphine treatment already existed (u.s. department of health and human services, ), but guidance from the us drug enforcement agency, samhsa, the centers for medicare & medicaid services, and state regulatory agencies changed rapidly ; opioid response network, ; providers clinical support system, a; substance abuse and mental health services administration, c) to allow greater flexibility of moud treatment via telemedicine during the pandemic. for example, the requirement for an in-person visit to begin moud was waived and dispensing of medications was allowed for longer periods of time. it is unclear how effective these changes will be or whether they will remain, but telemedicine is part of the oud treatment landscape and an important tool to support treatment access. "interim" treatment with methadone or buprenorphine refers to treatment with medication dispensed directly to patients (no prescription given) at licensed opioid treatment programs, which are heavily regulated at a federal and state level and require comprehensive ancillary services (e.g., on-site counseling). when there j o u r n a l p r e -p r o o f are waiting lists, these programs may receive regulatory approval to provide medication for up to days while patients await the full array of nonmedication services. this is called "interim" treatment and is superior to waiting lists on multiple outcomes including illicit opioid use and treatment retention (sigmon, ) . a medication unit is a satellite to a licensed opioid treatment program providing primarily medication dispensing in order to make treatment more accessible to patients (office of the federal register and government publishing office, b). new patients are required to have direct supervision of their daily dispensed medication for the first days of treatment, making travel a barrier to treatment if the program is located far away from the patient. therefore, medication units are a way to extend the availability of methadone treatment over a wider geographic region. the second submenu focuses on strategies that link people with oud to moud. there are two strategies to choose from: improving linkage to moud from venues where persons with oud may be encountered (e.g., general medical and mental health treatment programs, syringe service programs, and criminal justice settings); and using moud initiation as a bridge to longer-term care (starting moud at the venue where the patient is encountered in addition to linkage to ongoing moud treatment). on-site moud initiation strategies are preferred and can occur across multiple community-based settings such as in emergency departments and hospitals where patients may present with complications of untreated oud such as an opioid overdose or a deep-seated infection related to intravenous injection of opioids. starting moud in these venues is safe, feasible, and can significantly increase likelihood of continuing moud treatment (d'onofrio et al., ; weinstein et al., ) . c) moud treatment engagement and retention moud treatment retention beyond months is challenging (samples et al., ) , but critical to saving lives. research is clear that moud treatment retention is strongly associated with decreased mortalityboth from overdose and all-cause mortality, with risk of overdose increasing dramatically after discontinuation of moud (pearce et al., ; wakeman et al., ; walley et al., ; williams et al., ) . communities must choose at least one of the following five strategies: a) enhancement of clinical delivery approaches to support engagement and retention; b) use of j o u r n a l p r e -p r o o f virtual retention approaches; c) retention care coordinators; d) mental health and polysubstance use treatment integrated into moud care; and e) reducing barriers to housing, transportation, childcare, and accessing other community benefits for people with oud. comprehensive strategies to improve moud treatment retention include addressing each individual's treatment needs, which commonly include treatment for comorbid mental health and non-opioid substance use disorders as well as reducing barriers to resources such as housing, transportation, insurance coverage, food security, childcare, employment and other psychosocial and community services (substance abuse and mental health services administration, d). shared decision making, case management, legal assistance and advocacy, on-site psychiatric services and psychosocial recovery support, insurance navigation, behavioral interventions such as contingency management for comorbid non-opioid substance use disorders (de crescenzo et al., ) , and technology-delivered therapies (christensen et al., ) are some example strategies aimed at improving engagement and retention. opioid analgesic prescribing practices can increase the risk of long-term opioid use, the development of oud and opioid-involved overdose deaths. for example, an opioid analgesic prescription is associated with increased risk for oud in persons with chronic non-cancer pain (edlund et al., ) and the length of an initial opioid prescription for acute pain is a significant predictor of long-term use (shah et al., ) . similarly, high doses of opioids (e.g., > morphine milligram equivalents) (bohnert et al., ; dasgupta et al., ) , use of extended-release/long-acting opioids (zedler et al., ) and concurrent prescribing of benzodiazepines increase the risk of overdose (hernandez et al., ; sun et al., ) . those with cooccurring mood disorders, other non-opioid substance use disorders, chronic medical conditions, and chronic pain are at heightened risk (campbell et al., ) . when prescribed opioids are not properly stored or go unused, the excess supply is a potential source for non-medical use and/or diversion; the majority of persons reporting non-medical use of prescription opioids obtain them from a friend or family member (substance abuse and mental health services administration, a). numerous safer opioid prescribing guidelines have been published (chou et al., ; franklin and american academy of, ; manchikanti et al., ; nuckols et al., ) , however, adherence to these guidelines is low (hildebran et al., ; sekhon et al., ; starrels et al., ) . pain management education remains inadequate (mezei et al., ) , but is a key strategy to address poor adherence to j o u r n a l p r e -p r o o f guideline-based safer opioid prescribing practices. accordingly, the prescription opioid safety menu (table ) includes two submenus: a) safer opioid prescribing/ dispensing practices, which is required, and b) safer opioid disposal practices, which is optional. a) safer opioid prescribing/dispensing practices communities must select at least one of the following three strategies: ) safer opioid prescribing for acute pain across healthcare settings, such as inpatient services, emergency departments, outpatient clinics, ambulatory surgery and dental clinics; ) safer opioid prescribing for chronic pain, including adherence to the cdc guideline recommendations and patient-centered opioid tapering; or ) safer opioid dispensing. a variety of approaches have been effective in promoting safer opioid prescribing. for example, opioid prescribing changes were observed following implementation of the cdc chronic pain guidelines (bohnert et al., ) . online and in-person continuing education has been shown to improve knowledge, attitudes, confidence and self-reported clinical practice in safer opioid prescribing (alford et al., ) . academic detailing, an interactive one-on-one educational outreach by a healthcare provider to a prescriber to provide unbiased, evidence-based information to improve patient care, has been applied successfully to improve opioid prescribing behavior (larson et al., ; voelker and schauberger, ) . the utilization of state prescription drug monitoring programs to assess patients' controlled substance prescription histories and identify potential risky patterns of opioid use or drug combinations has resulted in reduced multiple-provider episodes (i.e., "doctor shopping") (strickler et al., ) , reduced high-risk opioid prescribing (strickler et al., ) , and reduced prescription opioid poisonings (pauly et al., ) . prescriber feedback regarding a patient's fatal overdose can also change prescriber behavior (doctor et al., ; volkow and baler, ) . most efforts to promote safer opioid analgesic use have focused on prescriber behavior change. however, pharmacists are the last line of defense against unsafe opioid prescriptions and have a corresponding responsibility to ensure legitimate prescriptions (office of the federal register and government publishing office, ). providing safe, convenient, and environmentally appropriate ways to dispose of unused prescription opioids can help reduce the excess opioid supply within communities and prevent access by children, adolescents, and other vulnerable individuals. communities have the option of selecting a j o u r n a l p r e -p r o o f strategy to promote safe disposal practices such as the installation of permanent disposal kiosks or the implementation of other disposal programs such as distribution of drug mail-back envelopes. studies have shown that leftover medication from an opioid prescription is common (bicket et al., ; kennedy-hendricks et al., ) and that patient education regarding disposal practices can increase opioid disposal rates (hasak et al., ) , although education about disposal is suboptimal (gregorian et al., ) . according to a recent study, only % of persons who had received an opioid prescription in the previous two years disposed of their unused opioid medication; however, over % indicated they would be more likely to dispose of opioid medications in the future if disposal kiosks were in a location they visited frequently (buffington et al., ). because the evidence base will evolve during the course of this study, additional strategies can be added to the menus if any of the following inclusion criteria are met: ) listed in a registry of ebps (federal, state, or community) that documents it has been replicated multiple times with positive effects; ) evidence of its efficacy through, at a minimum, a quasi-experimental design; ) evidence of its efficacy in reducing opioid-involved overdose death that has been published in a scientific journal; or ) it has been reviewed and approved by the orcca steering committee. upon completion of the orcca menus, the subgroups developed a companion technical assistance guide which provides greater detail about the resources included in the orcca menus (i.e., the resources listed in the "sample resources" column of tables - ). the resources compiled in the guide (e.g., toolkits, publications, websites) are designed to help implement and sustain each ebp and strategy included on an orcca menu and provides examples of successful national, state, and local programs. the guide is considered a "living document" and is updated every six months by a dedicated subgroup spanning the research sites. the hcs seeks to facilitate widespread uptake and expansion of three ebps with the potential to reduce opioid-involved overdose fatalities: ) oend; ) effective delivery of moud, including agonist / partial agonist medication; and ) prescription opioid safety. this paper described the j o u r n a l p r e -p r o o f development of the orcca, which includes a menu-based approach to organizing strategies and resources for facilitating implementation of these ebps. the orcca includes requirements and recommendations for ebp implementation to help ensure standardization across the research sites. at minimum, five strategies need to be selected to implement the three ebps: one for oend, three for moud, and one for prescription opioid safety. based on a literature review and expert consensus, the orcca requires identification, and engagement of, high-risk populations in healthcare, behavioral health, and criminal justice settings, which will help ensure both that individuals most in need of services receive them and that implementation of ebps will be more widespread in communities than could be achieved by allowing implementation within a narrower range of settings. importantly, the orcca does not prescribe the implementation of any single strategy; rather, it provides flexibility with multiple strategy options for implementing the required ebps, all of which were chosen based on the scientific evidence. because each community will vary in the need, feasibility, readiness, desirability, stage of current implementation, and expected impact for specific practices, they will likely differ in their strategies and venues for implementing the three required ebps. many of the resources included in the orcca menus and technical assistance guide have been developed to directly assist community coalitions, implementation teams, administrators, and practitioners who seek to implement or expand ebps. in the hcs, the implementation of selected strategies will be a partnership between the community coalitions and the research site team, with the research site providing technical support. a limitation of the approach taken to orcca development is that a formal systematic review of the literature, such as that outlined by the preferred reporting items for systematic reviews and meta-analyses (moher et al., ), was not completed and, thus, potential strategies that could effectively support ebp implementation may have been missed. a strength of the approach is that, in addition to meeting the needs of the hcs communities, the orcca was designed for dissemination to other communities struggling with the opioid crisis should the hcs model prove effective. the flexibility included in the orcca, along with the resources included in the orcca menus and the technical assistance guide, will increase the ease of implementation, with knowledgeable clinical experts in place of a research team, who partner with coalitions and organizations to select and implement practices that will achieve desired outcomes and foster sustainability. o single-item drug screening question (smith et al., ) o taps tool (tobacco, alcohol, prescription medication and other substance use) (mcneely et al., b; schwartz et al., ) o rapid opioid dependence screen (rods) (wickersham et al., ) o prescription drug monitoring program systems (huizenga et al., ) o o police assisted addiction recovery initiative o relay, a peer-delivered response to nonfatal opioid overdoses (welch et al., ) o recovery initiation and management after overdose (scott et al., ; scott et al., ) o j o u r n a l p r e -p r o o f oend by referral (e.g. prescription to fill at pharmacy guy et al., ; mueller et al., ) , referral to oend dispensing program (coffin et al., ; sohn et al., ) general resources/toolkits for oend by referral and oend by self-request o prescribe to prevent (lim, j. k. et al., ; prescribe to prevent, ) o getnaloxonenow.org training (simmons et al., ) o prevent & protect: pharmacy outreach to improve community naloxone access (prevent and protect, ) o oend self-request (e.g. at pharmacy, community meeting or public health department) (jones et al., ) naloxone availability for immediate use in overdose hotspots (naloxbox, ; salerno et al., ) naloxbox (mounted supply of naloxone) (naloxbox, ) (clark, l et al., ; samhsa-hrsa center for integrated health solutions, ) safer opioid prescribing for chronic pain (barth et al., ; bohnert et al., ; bohnert et al., ; dunn et al., ; edlund et al., ; gaiennie and dols, ; gomes et al., ; guy et al., ; jeffery et al., ; liebschutz et al., ) pain management guidelines and toolkits association between state laws facilitating pharmacy 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injectable naltrexone in the treatment of opioid us and mental health services administration state targeted response technical assistance c (american academy of addiction psychiatry and state targeted response technical assistanc • project echo practitioner locator (substance abuse and mental health services a american society o • harvard medical school free, accredited online courses in opioid use disorder education ○ understanding addiction ○ identification, counseling, and treatment of oud ○ collaborative care approaches for the management of oud expanding the use of medications to treat individuals with substance use disorders • procedures for medication-assisted treatment of alcohol or opioid dependence in primary c • getting started with moud with lessons from advancing recovery medications for oud (substance abuse and mental health services admin • samhsa mat guide for pregnant women with oud (substance abuse and mental health • samhsa tip : substance abuse treatment for persons with co-occurring disorders association: the opioid guide integrating buprenorphine treatment for oud in primary care • providers clinical support system overview of medication assisted treatment (providers cli • provider clinical support system mentoring program (providers clinical support system california department of health care services, ) and project "support shout and california health care foundation buprenorphine home induction smart phone application • national institute on drug abuse home induction guide • continuum of care echo: inpatient treatment programs and methadone providers office based addiction treatment clinical guidelines (boston medica • american college of emergency physicians addressing the opioid stigma in the initiating buprenorphine treatment in detoxification settings • association between mortality rates and medication and residential treatment • institute for health and recovery maternal opioid use during pregnancy toolkit (institute for quality collaborative • adolescent substance use and addiction program -primary care • integrating bup treatment in hiv primary care settings (target hiv intensive course series continuing medical education on controlled substance pr state-specific resources o kentucky • find help now kentucky (locate addiction specialty clinics) (find help now ky the massachusetts substance use helplin • journey recovery project pregnancy and parenting (journey recovery project • massachusetts health hospitals association guideline treating opioid use disorder in the e hospital association • protecting others and protecting treatment  national commission on correctional healthcare jail-based medication-assisted treatment: p resources for the field (national commission on correctional healthcare use of medication assisted treatment for opioid use disorder in criminal justice services administration medication assisted treatment in the criminal justice system: brief guidance to t health services administration  california health care foundation medication-assisted treatment in county criminal justice foundation principles of drug abuse treatment for criminal justice populations-a research-based guide  protocol for consent to treatment with medications for opioid use disorder in correctional f addiction services, ) expanding access to moud treatment through telemedicine, interim buprenorphine or methadone, or medication units  medication units: electronic-code of federal regulations - . (office of the  interim methadone: electronic-code of federal regulations - support for hospital opioid use treatment" webinar on telemedicine and moud t health care foundation linkage programs (all relevant settings) within (or initiated within) service settings • massachusetts post-overdose public health -public safety partnerships now what? the role of prevention following a nonfatal opioid overdose • police assisted and addiction recovery initiative • community reinforcement and family training (center for motivation and change • the minute guide • the foundation for opioid response efforts (foundation for opioid response efforts within outreach/field settings • colerain (cincinnati) quick response teams • safety and health integration in the enforcement of laws on drugs • harmonizing disease prevention and police practice model access to recovery (massachusetts access to recovery, ) peer navigation • ohio mental health & addiction services: peer recovery support • recovery coach academy (friends of recovery • providers clinical support system (providers clinical support system, a) and addicti interviewing training referral only • samhsa/hrsa three strategies for effective referrals to specialty mental health and for integrated health solutions review of post opioid overdose interventions in preventative medicine (bagl starting individuals on moud as an adjunct to linkage programs (all relevant settings within (or initiated within) service settings • samhsa tip : medications for oud (substance abuse and mental health services admin • california bridge (california department of use of medication assisted treatment for opioid use disorder in criminal justice services administration principles of drug abuse treatment of criminal justice populations: a research-based guid clinical use of extended-release injectable naltrexone in the treatment of opioid us and mental health services administration opioid response network (american academy of addiction psychiatry and state targeted re • harm reduction agencies as potential site for buprenorphine treatment addiction consultation services -linking hospitalized patients to outpatient addiction treatme • a transitional opioid program to engage hospitalized drug users ) c) moud treatment engagement and retention (required) retention use of psychosocial interventions in conjunction with medications for clinical support system with community reinforcement approac incentives (center for the application of substance abuse technologies use of virtual retention approaches (e.g., mobile, web, digital therapeutics) (pear therapeutics, ; substance abuse and mental health services administration • reset® prescription digital therapeutic software (pear therapeutics computer-based training for cognitive behavioral therapy (carroll • connections smartphone app program reviews (center for technology and b utilize retention care coordinators • samhsa: wraparound implementation and practice quality standards hiv care coordination program (centers for disease control and • patient-centered primary institute care coordination tip sheet (patient-centered primary care • patient-centered primary institute referral and care coordination (patient-centered primary c • boston medical center office based addiction treatment continuum of care echo (boston • boston medical center nurse care manager office based addiction treatment (boston medic mental health and polysubstance use treatment integrated into moud care preventing addiction related suicide general principles for the use of pharmacological agents to treat individuals wi disorders tip : substance abuse treatment for persons with co-occurring disorders pharmacologic guidelines for treating individuals with post-traumatic stress dis (substance abuse and mental health services administration association learning center: treating co-occurring depression and op • integrated group therapy bipolar and substance use disorders unified protocol for the transdiagnostic treatment of emotional disorders with community reinforceme motivational incentives (center for the application of substance abuse technologies • addiction technology transfer center network motivational interviewing training (addictio • providers clinical support system webinars (providers clinical support system brief: substance use and suicide: a nexus requiring a public health approach services administration tip : addressing suicidal thoughts and behaviors in substance abuse treatmen services administration and center for substance abuse treatment • national institute of mental health suicide prevention website (national institute of mental h • suicide prevention resource center programs and resources (substance abuse and mental health servic • ryan white hiv/aids medical case management the massachuse • ohio recovery housing (ohio recovery housing, ) • kentucky: voices of hope chrysalis house (residential sud treatment and supportive housing) (chrysalis hou • kentucky: acquired immunodeficiency syndrome volunteers ky (supportive housing, recove moud =medication for opioid use disorder samhsa=substance abuse and mental health services administration; echo =extension for community healthcare outcomes; hrsa= the health resources and services administration key: cord- -a svuwu authors: kavčič, tina; avsec, andreja; zager kocjan, gaja title: psychological functioning of slovene adults during the covid- pandemic: does resilience matter? date: - - journal: psychiatr q doi: . /s - - - sha: doc_id: cord_uid: a svuwu as a public health emergency, a pandemic increases susceptibility to unfavourable psychological outcomes. the aim of the present study was to investigate the buffering role of personal resilience in two aspects of psychological functioning, mental health and stress, among slovene adults at the beginning of the covid- outbreak. within five days after slovenia declared epidemics, participants ( % female) completed an on-line survey measuring mental health and perceived stress as outcome variables and demographics, health-related variables, and personal resilience as predictor variables. hierarchical logistic regression analyses demonstrated that women, younger, and less educated participants had higher odds for less favourable psychological functioning during the covid- outbreak. in addition, poorer health indicators and covid- infection concerns predicted diminished psychological functioning. the crucial factor promoting good psychological functioning during the covid- pandemics was resilience, additionally buffering against detrimental effects of demographic and health-related variables on mental health and perceived stress. while previous research suggests that mental health problems increase during pandemics, one way to prevent these problems and bolster psychological functioning is to build individuals’ resilience. the interventions should be targeted particularly at younger adults, women, less educated people, and individuals who subjectively perceive their health to be rather poor. a pandemic as a public health emergency in itself increases the proneness of people to various mental health problems, which may be further aggravated by the social distancing approach disrupting daily routines, restraining interpersonal communication and limiting the availability of social support [ , ] . while modern world has faced other epidemics and pandemics before, none of them had such world-wide and drastic effects on most of the individuals and their everyday life as the current covid- pandemic. the present study aimed to elucidate people's psychological functioning at the beginning of covid- outbreak. besides investigating the role of demographic characteristic and health-related variables in two aspects of individuals' psychological functioning -stress and mental health, special research interest was focused on examining the buffering role of personal resilience. on th of march the world health organization [ ] recognized the covid- as a pandemic. many countries, including slovenia, took increasingly stricter measures directed towards flattening the curve, i.e. slowing the infection rate of the virus across the population. these measures were primarily focused on social distancing and were to be continued for an unpredictable time. the present study was carried out during the first days of lockdown, characterized by significant changes in all aspects of people's daily lives and high overall worry about the infection, inflated by the exponentially increasing infection and death rates in the neighbouring regions of italy. studies carried out during previous recent outbreaks, such as the - sars epidemic [ ] , influenza a h n pandemic [ ] , - mers outbreaks [ ] , and the - ebola epidemic [ ] , suggested that such outbreaks are accompanied by significant psychological stress in healthcare workers and general population. increased mental health symptomatic seem to accompany the current covid- pandemic as well [ ] [ ] [ ] . among personal factors affecting psychological functioning during adversity, resilience has been suggested to have a buffering role in pandemic-related stress [ ] . the present study investigated resilience at the individual level as a personal quality that helps individuals to thrive in the face of adversity [ ] . the positive role of resilience in various stressful situations and life outcomes has been well-documented [ ] , but its effects on psychological functioning during virus outbreaks remains understudied with a few exceptions [ ] . the aim of the present study was to examine psychological functioning during the first days after the declaration of covid- pandemic. we aspired to broaden existing knowledge on psychological functioning during such public health crises by focusing not only on mental health problems (i.e. stress levels) but also on positive mental health, thus adopting the modern view of mental illness and mental health as separate though related entities [ , ] . moreover, we investigated the role of potential predictors of psychological functioning. in addition to more commonly explored role of demographic and health-related variables, including people's concern about covid- infection, this study also explored the incremental predictive value of individuals' personality resilience in the context of covid- pandemic. more precisely, resilience was expected to have a two-fold buffering effect: it could (i) inoculate individuals against elevated stress levels and decreased mental health, as well as (ii) weaken the negative impact of potential risk factors (e.g., pre-existing health conditions) on stress and mental health. the total sample consisted of participants with a mean age of . years (sd = . ). among them, . % were emerging adults ( - years), . % were early adults ( - years), . % were middle adults ( - years), and . % were late adults ( - years). a quarter of the participants ( . %) were male and three quarters ( . %) were female. regarding their education, . % had a high school or lower education and . % attained a post-secondary education or graduate degree. the data were collected within five days after slovenia declared epidemics. during these five days, the government closed all sales and service facilities (with the exception of food and pharmacy stores), schools and kindergartens, stopped public transportation, and prohibited public gatherings. furthermore, covid- claimed its first victim in slovenia. the data collection took place via an on-line survey platform. the link was distributed via social networks and advertised on the national radio and television's website. on the first page of the survey, the participants were informed about the aims of the study and asked to confirm their informed consent to participate. demographic data collected included information on sex, age, and educational level. the general health indicators included the presence of at least one chronic health condition (yes/no answer) and subjective reports of health, assessed along a continuous scale ranging from (very bad) to (very good). two contextualized health-related variables tapped the degree of worry regarding their own and their significant others' possible covid- infection, assessed on a continuous scale ranging from (not at all) to (very good). all continuous scale-scores were dichotomized with scores up to and including regarded as poor health/not worried and scores above as good health/worried. the item connor-davidson resilience scale -cd-risc- [ ] is a self-report scale that measures how well is one equipped to bounce back after adversity. each item is rated on a -point scale ( not true, true nearly all of the time). in the present study, the participants reported on their resilience for the past week. previous studies had shown good reliability, validity [ ] , and measurement invariance across age and sex [ ] for the cd-risc- . alpha reliability coefficient in our sample was . . the resilience score was dichotomized based on a median split (< vs. ≥ ). the perceived stress scale -pss [ ] is a self-report -item scale, designed to measure the degree to which situations in one's life are appraised as stressful. using a -point rating scale ( never, very often), participants specify how often did they feel or think in a certain way during the last week. the reliability and validity of the pss had been established as satisfactory [ ] . in our study, the alpha reliability coefficient was . . the perceived stress score was divided into the categories of low vs. high perceived stress based on a median split (< vs. ≥ ). the short form of the mental health continuum -mhc-sf [ ] consists of items that measure positive mental health. the overall score reflects emotional, psychological and social well-being. respondents rate the items on a -point scale ( never, every day during the past week). the mhc-sf has shown good internal consistency and sound validity [ ] . the alpha coefficient obtained with our sample was . . the presence of flourishing mental health is indicated when a person feels at least one of the three hedonic well-being symptoms "every day" or "almost every day" and at least six of the eleven psychological and social well-being symptoms "every day" or "almost every day" in the past week. the absence of flourishing mental health reflects moderate to poor well-being. demographic characteristics and descriptive statistics were examined for the entire sample and separately for those with flourishing vs. non-flourishing mental health and low vs. high perceived stress in the past week. overall, . % (n = ) participants were classified as having flourishing mental health in the past week and . % (n = ) participants perceived high levels of stress. more precisely, . % of the sample had favourable scores on both indicators of mental health and . % disadvantageous scores on both indicators, while . % reported low stress and low flourishing, and . % high stress and flourishing mental health. next, chi-square tests were performed to examine the association of independent variables with flourishing mental health and high perceived stress. generally, flourishing mental health was more common among men, older participants, and highly educated participants (table ) . flourishing was also more common among participants who reported having good health, had no chronic health conditions and were less worried about their own and other's potential infection with covid- . high stress was associated with female sex, younger age, lower educational level, lower subjective health and worrying about one's own and other's potential infection with the new coronavirus. finally, the strongest association was observed between high resilience and both indicators of good psychological functioning. hierarchical logistic regression modelling was employed to examine independent effects of demographic characteristics, health-related variables, and resilience on flourishing mental health and high perceived stress. in the first step, age, sex, and education were entered as covariates in the models. in the second step, self-rated health, chronic health conditions, and worry about one's own and other's potential covid- infection were added to the models. finally, resilience was entered in the models. except from age, all predictors were treated as categorical. the results of the first step of the hierarchical logistic regression models (table ) revealed that men, older, and more educated participants were more likely to have flourishing mental health during the previous week compared to women, younger, and less educated participants, who were instead more likely to report being highly stressed. both regression models were significant, but explained rather low shares of variance in the dependent variables (see nagelkerke r values in table ). adding health-related variables to the models as covariates revealed that participants who rated their health as poor, reported having chronic health condition(s), and were worried about their own and other's potential covid- infection were less likely to have flourishing mental health in the previous week, but more likely to report high perceived stress (with one exception the presence of chronic health conditions was not a significant predictor of high stress). the associations with sex, age, and education remained stable. again, both models were significant and some additional variance was explained in the two dependent variables. lastly, participants who were more resilient during the previous week had almost times higher odds of flourishing mental health and . times lower odds of high stress levels compared to those who were less resilient. this was by far the strongest predictor in both models. moreover, resilience attenuated the negative effects of female sex, lower education, and health-related variables on flourishing mental health. apart from poor self-rated health, these covariates no longer had significant negative effects. the attenuation effect of resilience was also observed when predicting high levels of stress, although it was weaker, with most of the predictors from previous steps remaining significant. the two final models were significant, with % and % of variance explained in flourishing mental health and high perceived stress, respectively. the present study investigated the buffering role of personal resilience in two aspects of psychological functioning, stress and mental health, during the outbreak of covid- and subsequent social lockdown, while taking into account individuals' demographic and healthrelated characteristics. the results obtained showed that demographic characteristics and health-related variables contribute significantly to favourable psychological functioning during the covid- pandemic, but their predictive value is rather weak and diminishes further once personal resilience is note. * p < . , ** p < . , *** p < . accounted for. nevertheless, younger age seems to represent a risk factor for poor psychological functioning during the pandemic, which is consistent with findings in china [ ] . this results could be seen as counterintuitive as the symptoms and consequences of the new coronavirus are worse for older as compared to younger adults [ ] . however, there is some evidence that flourishing is more common in middle and late adulthood than early and emerging adulthood [ ] , and the present study suggests that this holds true even in the face of such an adversity as the covid- pandemic. in addition, the present results suggest that women may be at a higher risk for nonflourishing mental health and high stress. while the statistics show somewhat higher covid- mortality rates for men than women [ ] , our results are in line with the notion that other consequences of the pandemic and lockdown, such as financial challenges, increased informal care of children and their schooling as well as sick family members, and decreased employment opportunities, could be more detrimental for women than men [ ] . this finding is also consistent with previous research showing somewhat higher susceptibility of women to elevated levels of stress and mental health problems than men [ ] . finally, in line with previous findings [ , ] , our results indicated a protective role of higher education in good psychological functioning, although this association was weak and diminished to the level of insignificance after controlling for personal resilience. our results further suggest that the subjective perception of one's health is more important for perceived stress and mental health during pandemic than objective health indicators, such as the presence of chronic health conditions. the later variable was included as the covid- mortality rates are higher for people with other medical conditions than those without [ ] . however, according to our results psychological functioning outcomes seem to be more contingent on subjective assessment than objective measures of health functioning. furthermore, high concerns about possible covid- infection also proved a significant predictor of high perceived stress and lower levels of mental health. nevertheless, the predictive value of subjective and objective health indicators and infection concerns diminished substantially once the resilience was taken into account. as our results show, the crucial factor of psychological functioning during covid- pandemic seems to be individual level resilience. even after taking into account demographic characteristics and health-related variables, presumed to be associated with risk of covid- infection and mortality, the probability of experiencing high stress and flourishing mental health during the current pandemic and lockdown depends mostly on the level of personal capability to cope with adversity and achieve good adjustment. the results thus support the hypothesized buffering role of resilience against diminished psychological functioning due to the covid- pandemic and associated preventive measures that may have concurrent and long-lasting negative effects on diverse aspects of people's everyday lives. furthermore, resilience was found to buffer against detrimental effects of various demographic and health-related variables on mental health as it noticeably attenuated their role in stress and particularly in mental health. these findings corroborate the conceptualization of resilience as a trait that protects individuals against the impact of adversity or traumatic events [ , ] , and extend them to the context of the covid- pandemic with its unprecedented scope and wide-spread corollaries. the good news concerning our findings is that resilience can be effectively enhanced and thereby the risk of poor psychological functioning due to the pandemic and its consequences can be reduced. two evidence-based intervention programs may be especially suitable in the pandemic context [ ] : ( ) folkman and greer's approach [ ] promotes problem-focused coping for controllable events, emotion-based coping for boosting support and reducing isolation, and meaning-based coping for persistent events; ( ) the psychological first aid approach [ ] facilitates resilience immediately after trauma. in addition, previous studies provided evidence on effectiveness of several psychological interventions for boosting resilience, for example mindfulness [ ] , resilience regimen [ ] , self-efficacy training [ ] , and cognitive behavioural therapy [ ] . the american psychological association [ ] advises that individuals themselves can advance their resilience by building their social relationships (e.g., by keeping in touch with friends, accepting and offering support), fostering physical and mental wellness (e.g., practicing mindfulness, taking care of one's body), finding purpose (e.g., by helping others, being proactive, setting and moving towards realistic goals), embracing healthy thoughts (e.g., keeping things in perspective, accepting change, staying optimistic) and seeking professional help when feeling unable to function well. certain limitations of the study should be highlighted. first, the study relied on selfreported questionnaire data, which are susceptible to various biases [ ] . however, stress and well-being are inherently subjective phenomena and thus may be best assessed by selfreports. second, the data collection took place on an online survey platform. even though % of slovenians, aged from to years, regularly use the internet [ ] , the method of data collection and study advertising may have led to self-selection of participants, especially in late adults as half of the slovenian adults, aged over years never use the internet at all [ ] . the older adults who did participate in our study are (compared to the non-participating older adults) probably more familiar with modern digital technology, which could be associated with better cognitive and social functioning [ ] , leading to better mental health and confounding possible age effects investigated in our study. also, our sample was not representative in terms of sex structure, with more females than males participating. third, the study presented had a correlational cross-sectional design precluding any causal interpretations. to overcome this drawback, we asked the participants to continue taking part in the study and the follow-up data collection is under way. the main message for the policy makers, media, educators etc. is that while mental health problems increase during pandemics, one way to prevent these problems and increase good psychological functioning is to build individuals' resilience by educating general public and healthcare workers on evidence-based effective strategies, organizing and promoting intervention programs, and taking measures in work (especially healthcare) organizations aimed at fostering resilience. the results of the present study suggest that the intervention providers should pay special attention to younger adults, women, less educated people and individuals who subjectively perceive their health to be rather poor. in addition, our results support that it is important to consider indicators of both good and poor psychological functioning, as low stress does not necessarily imply flourishing mental health and vice versa [ , ] , and the predictive associations were not the same for stress and mental health. the psychological impact of quarantine and how to reduce it: rapid review of the evidence progression of mental health services during the covid- outbreak in china director-general's opening remarks at the media briefing on covid- - applying the lessons of sars to pandemic influenza initial psychological responses to influenza a, h n ("swine flu") healthcare workers emotions, perceived stressors and coping strategies during a mers-cov outbreak an evaluation of psychological distress and social support of survivors and contacts of ebola virus disease infection and their relatives in lagos, nigeria: a cross sectional study− the effect of covid- on youth mental health generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey prevalence and predictors of ptss during covid- outbreak in china hardest-hit areas: gender differences matter development of a new resilience scale: the connor-davidson resilience scale (cd-risc) a meta-analysis of the trait resilience and mental health the relationship between resilience, psychological distress and subjective wellbeing among dengue fever survivors evaluating the psychometric properties of the mental health continuum-short form (mhc-sf) world health organization. mental health: new understanding, new hope. geneva: who psychometric analysis and refinement of the connor-davidson resilience scale (cd-risc): validation of a -item measure of resilience the connor-davidson resilience scale: establishing invariance between gender across the lifespan in a large community based study the social psychology of health: claremont symposium on applied social psychology review of the psychometric evidence of the perceived stress scale evaluation of the mental health continuum short form (mhc-sf) in setswana speaking south africans report of the who-china joint mission on coronavirus disease chronological and subjective age differences in flourishing mental health and major depressive episode epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study covid- : the gendered impacts of the outbreak sex differences and stress across the lifespan education and mental health: do psychosocial resources matter? ssm popul health determining factors for stress perception assessed with the perceived stress scale (pss- ) in spanish and other european samples q&a on coronaviruses (covid- ) psychological resilience, positive emotions, and successful adaptation to stress in later life promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other national child traumatic stress network and national center for ptsd. the psychological first aid: field operations guide mindfulness-based stress reduction (mbsr) enhances distress tolerance and resilience through changes in mindfulness how to bounce back from adversity resilience building in students: the role of academic self-efficacy strengths-based cognitive-behavioural therapy: a four-step model to build resilience building your resilience information bias in health research: definition, pitfalls, and adjustment methods usage of internet in households and by individuals the "online brain": how the internet may be changing our cognition publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.tina kavčič is an associative professor at faculty of health sciences, university of ljubljana, slovenia. she teaches courses on health psychology, personality psychology, psychology in healthcare and psychology in physiotherapy. her research interests are focused on personality development, factors of well-being, and social relationships in different developmental periods.andreja avsec is an associative professor at department of psychology, faculty of arts, university of ljubljana, slovenia. she teaches courses on personality psychology, individual differences, and positive psychology. her research interests are focused on personality traits and their outcomes, well-being, flow, and emotional intelligence.gaja zager kocjan is an assistant professor at department of psychology, faculty of arts, university of ljubljana, slovenia. she teaches courses on personality psychology, and psychology of emotions and motivation. her research interests are focused on measurement issues in psychology, personality change, flow, and mental health. key: cord- -w zqxwdh authors: kanekar, amar; sharma, manoj title: covid- and mental well-being: guidance on the application of behavioral and positive well-being strategies date: - - journal: healthcare (basel) doi: . /healthcare sha: doc_id: cord_uid: w zqxwdh the raging covid- pandemic has been a great source of anxiety, distress, and stress among the population. along with mandates for social distancing and infection control measures, the growing importance of managing and cultivating good mental well-being practices cannot be disregarded. the purpose of this commentary is to outline and discuss some research-proven positive well-being and stress reduction strategies to instill healthy coping mechanisms among individuals and community members. the authors anticipate that usage of these strategies at the individual and the community level should greatly benefit the mental well-being not only in the current covid- pandemic but also in any future epidemics at the national level. covid- is an unprecedented pandemic affecting people all over the world. as of august , covid- (caused by the novel coronavirus) has caused , , cases and , total deaths in the united states [ ] and , , cases and , deaths worldwide [ ] . the pandemic is still raging havoc at the time of writing this article. pandemic by definition means when a disease or a condition spreads across countries and continents [ ] . the covid- pandemic with its uncertainty has imposed great mental distress on the general public, its patients, and healthcare providers [ ] . the pandemic and its constant reporting in the media have increased distress-related psychological problems such as anxiety, depression, and insomnia [ , ] . at present, there is no established treatment for covid- or any vaccine for specific protection against it. the testing for covid- is not widely available and lacks desirable sensitivity and specificity [ , ] . the testing of its antibodies is also not quite accurate or readily available. hence, the current public health measures include preventing person-to-person transmission of the disease by separating people. among the approaches that are being used are ( ) isolation in which infected persons are separated from non-infected individuals; ( ) quarantine and fever surveillance of contacts who have been exposed but are not yet symptomatic; ( ) community containment in which social distancing and movement of the general public is restricted by efforts such as "stay at home orders" (community-wide quarantine) [ ] . such measures further compound the emotional distress being experienced by individuals. the pandemic also has an important economic aspect to it with millions of people losing their employment, which is a great source of emotional distress [ , ] . the fear associated with this pandemic is responsible for the activation of the hypothalamuspituitary-adrenal (hpa) axis [ ] . the hypothalamus liberates the corticotrophin-releasing hormone (crh) in response to emotional distress, which in turn, activates the pituitary gland to liberate the adrenocorticotropic hormone causing the liberation of cortisol from the adrenal cortex. cortisol, a glucocorticoid hormone, affects the body in several ways. for example, it affects the sleep/wake cycle, it affects the glucose metabolism, it regulates the blood pressure, and it boosts energy so one can handle stress [ ] . all these effects eventually drain the body's energy resources in the long run and also compromise immunity and mental resilience [ ] . although the centers for disease control and prevention (cdc) have provided some guidelines to reduce stress and initiate coping [ ] , the need of the hour seems to be planning and having resources and techniques for long-term mental health flourishing and better emotional health management. recent reports from the world health organization calls for global action to invest in and strengthen mental health services to avert an impending mental health crisis [ ] . mental health denotes emotional, psychological, and social well-being [ ] . positive mental health and positive psychology have an imminent role to play during this unprecedented public health crisis. although there is enough evidence-based literature on the application of positive mental health techniques at individual level for stress reduction or life fulfillment, its application in a pandemic scenario is minimally explored [ , ] . the purpose of this commentary is to address the unexpected and uncertain situation experienced due to this pandemic (which is to cause anxiety, alarm, panic) and a deep sense of ongoing fear by providing readers with research-proven techniques and strategies for generating and maintaining momentary and lifelong happiness, fulfillment, and entitlement to positive being and positive living. some of the strategies such as nurturing and maintaining social connections (while maintaining physical distancing), mindfulness and momentary living, goal commitment, and resilience [ ] will be explored, particularly from its applicability to the current covid- pandemic. the authors will additionally explore the science of gratitude development and maintenance as a strong strategy in this pathway. happiness strategies classically outlined in lyubomirsky's book "the how of happiness" revolve around (a) living in the present, (b) managing stress (which is outlined later in this article), and (c) investing in social connections [ ] . similarly outline strategies of broadening your thinking, raising your positivity-ratio, and disputing negative thinking and fear (which is obvious during pandemics) greatly assist in maintaining well-being at its highest levels [ ] . mindfulness meditation practice daily helps in quieting one's mind and prevents the constant internal mental chatter. this is additionally proven to focus your attention on the present moment and a lot of existing research has proven the efforts of its practice in maintaining and nurturing improved mental health. [ , ] . for example, the student population has greatly benefitted from a mindfulness course in terms of improved well-being, decreased stress, and increased resilience [ ] . similar benefits were noted in diverse populations such as older adults [ ] , adolescents [ ] , and educators [ ] . a systematic review [ ] and another meta-analysis [ ] found that mindfulness-based stress reduction (mbsr) was effective in reducing stress, depression, anxiety, and distress and in improving the quality of life of healthy individuals. the role of religion and prayer in reducing stress cannot be overemphasized such that studies have proven that prayer plays a significant role which is no less than meditation and other mind-body techniques in reducing stress [ ] . social connections (some of which are explained later) have shown proven associations between long-term well-being [ ] [ ] [ ] , and this could be practiced in a 'lockdown' environment by way of telephonic, message, and video-contact with family, friends, and colleagues. the role of dispositional and/or trait gratitude in mental well-being is a comparatively recent development in positive psychology [ , ] . there are some possible mechanisms of applying gratitude for generating positive mental well-being leading to prolonged life satisfaction and flourishing in life such as: (a) savoring positive life experiences, particularly in eras of pandemics such as spending time with your kids, having healthy meals or pursuing hobbies while being indoors could be joyful; (b) building positive emotions, which help in creative activities such as writing, playing an instrument, painting, and singing, and finally (c) engaging in social connections via electronic means and video-chats with family and friends, which assist in generating social bonds leading to improved relationships, elevated self-esteem, and overall psychological well-being [ ] living indoors and not going outdoors due to 'lockdowns' in a pandemic provides an individual level opportunity for self-introspection and assessing and reframing current and planned events through a positive lens and engaging in active problem solving [ ] . building and maintaining gratitude through actions of kindness, being thankful that one is living, and enjoying all the benefits that life offers also helps in coping with stressful situations by building lifelong resilience [ ] . there are several determinants of positive mental health such as hardiness, sense of coherence, social support, optimism, and self-esteem [ ] that are important in the context of covid- . according to the hardiness theory [ ] , three attributes can enhance our coping. the first one is "control" that pertains to one's belief that one can influence the environment. in the case of covid- , the control can come from taking all the precautionary measures that are under one's control. if one has lost his or her job, one needs to still maintain a sense of control and continue trying for alternatives. adhering to such measures will help one endure the adverse effects of distress and have better mental health. the second attribute in hardiness is that of "commitment", which pertains to one's deep involvement in whatever one does. with covid- , if one is confined to the home one can get involved in creative activities such as writing, cooking, drawing, and other activities that keep one busy. searching for a job if one has lost one's job with commitment will also lower distress. such commitment to everyday activities will help cope with stress and achieve better mental health. the third and final attribute of hardiness is that of "challenge", which pertains to one's ability to undertake change, confront new activities, and seek avenues for growth. the covid- pandemic provides ample opportunity for the challenge, which if harnessed appropriately, can foster positive mental health. the second theory that is of relevance to covid- is the sense of coherence theory [ , ] . the three components of the sense of coherence are comprehensibility, manageability, and meaningfulness. comprehensibility pertains to the ability to see the stressor that one faces as making some sense in the context of its structure, consistency, order, clarity, and predictability. with covid- , the comprehensibility of the stressor is lost and replaced with uncertainty, which results in distress. the second component of manageability pertains to the ability to believe that the resources under one's control are sufficient to meet the demands posed by the stressors. with covid- , one may at times feel that one is overwhelmed, but once again reminding oneself that the problem is temporary and the solution is inbuilt in the problem will go a long way in lowering distress and fostering positive mental health. the final aspect of the sense of coherence is that of meaningfulness, which pertains to the belief that life makes sense, and that the stressors in life are worthy of putting efforts into dealing with. it requires accepting stressors in life as challenges instead of feeling that they are burdensome. this type of attitude in dealing with covid- -related crises of any kind is vital not only in dealing with emotional distress but also in succeeding in life. the third theory that is of relevance in the covid- pandemic is that of social support, which is the help obtained through social relationships [ , ] . social support was classified into four kinds: ( ) emotional support that requires the provision of understanding, caring, love, and fosters reliance; ( ) informational support that requires the provision of information, counsel, and guidance; ( ) instrumental support that requires the provision of tangible help; ( ) appraisal support that provides evaluative help. during these times of covid- pandemic, all these types of social support are very much needed. one needs emotional support to buffer emotional distress; one needs informational support to keep abreast with latest developments on the disease, resources, and opportunities; one needs instrumental support in the form of tangible resources, and one needs appraisal support on various facets of dealing with the pandemic and its influence on one's life. another theory linked to good mental health is that of optimism [ ] , which requires one to expect the best possible outcome in any situation and is a learned behavior [ ] . optimism, in the covid- context, will operate through enhancing one's efforts to avoid the disease by increasing one's attention to information regarding its threat, directly improving coping, and building a positive mood. a final theory that is popular in the mental health field and common parlance is that of self-esteem [ , ] . a favorable attitude of oneself or confidence in one's self-worth is very important for mental health and must be maintained during the covid- pandemic no matter what the circumstances are. the concept of 'death anxiety'-the anxiety and psychological distress among human beings due to thoughts related to fear of death in the current covid- pandemic-has been growing recently such that 'coronaphobia' has been quite evident as a construct predicting generalized anxiety along with death anxiety across the population [ ] . fortunately, this anxiety can be measured [ ] and techniques used to manage it. although some of the strategies as suggested by the world health organization such as minimizing news feeds and promoting social media usage could be beneficial [ ] , emerging research suggests the role of positive self-talks and cognitive behavior therapy as effective modalities to modify or attenuate the 'death anxiety' [ , ] . thought interference, particularly annoying thoughts related to fear of death due to covid- can be very disturbing for individuals, and these strategies promote the 'problem-centered' coping style [ ] for stress reduction and, along with the behavioral strategies mentioned earlier, could be highly effective. the covid- pandemic continues to dominate the public health field. the authors believe that although the initial panic caused by the pandemic has mitigated to some extent its effects (such as anxiety, stress, fear, and uncertainty) will continue to linger for months ahead. there were a number of theories discussed in this commentary such as the hardiness, sense of coherence, and the social support theory. these theories when applied to a pandemic scenario, such as the current covid- scenarios, greatly helps us shape our understanding of the impact that this pandemic is having on anxiety, fear, and stress. social support theory guides us in managing and coping with these mental health conditions. future research should be aimed at the application of these theories in improved understanding of the role they play specifically in the covid- pandemic, and how the constructs of these theories could be modified to enhance mental health and well-being among covid- affected individuals. social support theory-based constructs could be utilized in developing and implementing interventions in preventing and promoting mental health in covid- affected individuals. additionally, the behavioral and positive well-being strategies outlined and discussed in this commentary provide guidance not only to individuals and community members at the frontline of this pandemic but also to people staying at home due to 'stay at home' orders. it behooves us to make use of as many behavioral strategies in our repertoire in these unprecedented and precarious times. funding: there were no funding sources we would like to acknowledge for this article. the authors declare 'no conflict of interest'. coronavirus disease : cases in the us rolling updates on coronavirus disease (covid ) covid and its mental health consequences public mental health crisis during covid- pandemic progression of mental health services during the covid- outbreak in china antibody testing for covid antibody 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predicting death anxiety death anxiety in the time of covid- : theoretical explanations and clinical implications disease perception and coping with emotional distress during covid- pandemic: a survey among medical staff key: cord- -begnpodw authors: yeasmin, sabina; banik, rajon; hossain, sorif; hossain, md. nazmul; mahumud, raju; salma, nahid; hossain, md. moyazzem title: impact of covid- pandemic on the mental health of children in bangladesh: a cross-sectional study date: - - journal: child youth serv rev doi: . /j.childyouth. . sha: doc_id: cord_uid: begnpodw covid- pandemic poses a significant mental health threat among children in bangladesh. this study aims to explore the impact of covid- on the mental health of children aged< years during the lockdown in bangladesh. an online cross-sectional study was conducted from th april to th may among parents having at least one child aged less than years using non-probability sampling. k-means clustering used to group children according to mental health score and confirmatory factor analysis (cfa) performed to identify the relationship among the parental behavior and child mental health, and also these associations were assessed through chi-square test. children were classified into four groups where % of child had subthreshold mental disturbances (mean major depressive disorder (mdd)- ; . ), . % had mild (mean mdd- ; . ), . % suffered moderately (mean mdd- ; . ), and . % of child suffered from severe disturbances (mean mdd- ; . ). the higher percentage of mental health disturbances of children with the higher education level of parents, relative infected by covid- (yes), parents still need to go the workplace (yes), and parent’s abnormal behavior but lower to their counterparts. this paper demonstrates large proportions of children are suffering from mental health disturbances in bangladesh during the period of lockdown. implementation of psychological intervention strategies and improvement in house-hold financial conditions, literacy of parents, taking care of children, and job security may help in improving the psychological/mental status of children and the authors believe that the findings will be beneficial to accelerate the rate of achieving the sustainable development goal (sdg) linked to health status in bangladesh. the outbreak of novel coronavirus disease has emerged in china, which rapidly spread the oddment of the world, and who declared it as a pandemic . the pandemic has been escalating and threatening the welfare of human beings globally and already transmitted to more than million people around the globe with at least , deaths as of july , (world health organization, a . to halt the covid- transmission and cease the burden on health systems all most all of the countries have brought unprecedented efforts to institute the practice of "social distancing", as a result, many schools have been closed (lancker & parolin, ) and classes are shifted to home-based distance-learning models (golberstein et al., ) . children are not beyond the grasp of this pandemic, and also the most vulnerable to the drastic effects of it, as they are forced to stay home for extended periods due to lockdown and school closure, resulting in minimal interaction with peers and decreased the opportunities for exploration and physical activities (jiao et al., ) . all of these adversely impact children's mental health and welfare, leading to a wide variety of mental health issues, such as anxiety, stress, depression, and sleeping difficulties (dunleavy, ; galvin, ; rawstrone, ) . to prevent the outbreak of covid- , bangladesh have been closed the academic institutions, therefore, about . million students and more than a million teachers are staying at home . although the scientific controversy is unremitting concerning the effectiveness of school closures on virus transmission (lancker & parolin, ) . schools play an emergent role, not just in supplying educational resources to children, but also in offering students an opportunity to communicate with teachers and receive psychological counseling (brazendale et al., ) . moreover, evidence shows that whenever children are beyond schooling (e.g. weekends and summer payday's), they become physically less active, have much-prolonged screen time, irregular sleep schedules and less healthy diets, resulted in excess weight and lack of cardiorespiratory performance (brazendale et al., ) . furthermore, pandemic stressors such as terror of infection, dissatisfaction and boredom, lack of knowledge, lack of personal space at home, and family's financial loss may have even more troublesome and enduring impacts on children mental health (brooks et al., ) . to assess the impact of home quarantine on children's mental health, a study was performed among , chinese children and identified that one in five children ( percent) in china was either suffering from depression or anxiety, or both (dunleavy, ) . also, mental health issues remain fairly elevated among u.s. children due to the covid- pandemic. according to the centers for disease control and prevention, . million children between the ages of to years have been diagnosed with anxiety and . million have been identified with depression because of home quarantine due to . moreover, about three in four children having depression along with anxiety (galvin, ) . the effect of the covid- pandemic on children's mental well-being is worrying % of parents, according to a survey by parents with primary-aged children and % reported that their children were missing school and less than half stated that their children were feeling lonely, which altogether affects their children's mental health and wellbeing (rawstrone, ) . in bangladesh, as the number of covid- cases continues to rise thus an immediate public health response is urgently needed (banik et al., ) . consequently, the government of bangladesh enforced full lockdown and all schools were closed from may , (kamruzzaman & sakib, ) , which negatively impact children's wellbeing through interruption of their health care, nutrition, security, education, and overall mental health (joining force bangladesh, ). yet, there is no literature available in bangladesh on the long-term impact of covid- pandemic on children's mental health. thus, it becomes important to determine how extended school closures, stringent social distancing steps and the pandemic itself have impacts on the mental health status of children. therefore, this study aimed to investigate the impact of the covid- pandemic on mental health and determining the associated factors among children of bangladesh. this study was conducted among parents having children in bangladesh through an online survey between th april to th may, after completing days of home-quarantine following lockdown declaration on th march by the government of bangladesh (world health organization, b). here, non-probability sampling (purposive sampling) techniques were used to collect the primary data from participants. firstly, parents who had at least one child aged between - years, known to the researchers by their facebook friends were invited to complete the survey by filling the questionnaire. we have calculated the sample size using the following where, we considered z = . and d = . confidence interval as . . the sample proportion was assumed as . since this value provide the maximum sample size. hence, the required sample size was . however, a total of respondents completed the survey and after cleaning the incomplete responses participants were taken for final analysis. the primary data was collected via an online questionnaire as the face-to-face interview had to be avoided due to ongoing lockdown. the questionnaire was pilot-tested in a sample of subjects before the final study initiation. we sent the link of designed google form to the parents randomly and the inclusion criteria were having at least one child aged between - years. the questionnaire consisting of several parts such as (i) socio-demographic information (age, sex, educational level, place of living, number of earning members in the family, average monthly family income, knowledge about covid- , and any family member/relatives/neighbor of the respondent was corona positive or not), (ii) financial and lifestyle information of parents, (iii) information related to child's activity and attitude of parents toward child and (iv) mental health related information of child. participants were given no economic motivation, and anonymity was maintained to make sure data confidentiality. first of all, asking the consent of participating in the survey and it was also notified that at any time, participants could revoke from the survey without giving any justification. this study was carried out online in full conformity with the provisions of the helsinki declaration on human participant research. the -item revised child anxiety and depression scale (rcads) (chorpita et al., ) includes the -item depression total scale in order to measure children's major depressive disorder (i.e., the child feels sad or empty, nothing is much fun, trouble in sleeping, problems with appetite, no energy for things, tired a lot, cannot think, feels worthless, doesn't want to move, & feels restless). children's anxiety was assessed by the generalized anxiety disorder (gad) scale with the help of spence child anxiety scale for parents (scas-p) (nauta et al., ) . also, gad is a -item questionnaire (e.g. my child worries about things, complains of having a funny feeling in his/her stomach, complains of feeling afraid, heart beating fast, child worries that something bad will happen, & feels shaky). parent-reported child behavior checklist (cbcl) (achenbach & edelbrock, ) , a questionnaire to assess children's behavior/emotional problems at ages of - years. a "sleep problem scale" was ascertained by six items from the cbcl ("experiences nightmares," "sleeps less than most children," "sleeps more than most children," "talks or walks in sleep," "trouble sleeping," and "overtired"). the mdd- and gad- scales are evaluated at -points ( =never, = once in a week, = - times in a week, & = everyday) which gives a total score of to and to respectively. moreover, sds- used a -point scale ( =not true; =sometimes true; =very true/often true) which gives a total score of to . the higher scores indicate higher level of depression, anxiety, and sleeping disorder. the acceptable reliability test was performed and the value of cronbach alpha was . which is more than the acceptable value of . . firstly, descriptive statistics were performed to describe the basic demographic characteristics of the respondents. secondly, k-means clustering analysis was applied to cluster depression, anxiety, and sleeping disorder scores (kang et al., ) of a child. the chi-square test was used to measure the association of socio-demographic variables, parental behavior towards children, and child mental health scores among the cluster. thirdly, a confirmatory factor analysis (cfa) was constructed to explore the components associated with child mental health. finally, a structural model was developed using the identified components of child mental health (hu & bentler, ) . the significance level is set at a p-value< . here. data analysis is performed using ibm spss among the participants, there are ( . %) female and ( . %) male respondents. the majority of the participants tended to be aged - years ( . %), had an educational level of post-graduation ( . %), and lived in the urban areas ( . %). a total of . % of the respondents were involved in a job during the lockdown, where . % of participants needed to go to the table ]. [ table here] the depression, anxiety, and sleeping disorder scores of children were classified into groups (sub-threshold, mild, moderate, and severe disturbance) using k-means clustering. results depict that % of child had subthreshold mental health disturbances (mean depression: . , anxiety: , and sleeping disorder: ), . % had mild disturbances (mean depression: . , anxiety: . , and sleeping disorder: ), . % suffered from moderate disturbances (mean depression: . , anxiety: . , and sleeping: ), and . % suffered from severe disturbances (mean depression: . , anxiety: . , and sleeping disorder: ). significant differences found in the depression, anxiety, and sleeping disorder scores of the child among the four groups using the chi-square test, as shown in table . [ table here] the chi-square test was used to find significant differences in several characteristics among the four groups. results reported that there were no significant differences in sex and age of the parents among the four groups. but significant differences found in the educational level of parents, place of living, any relative/neighbor of child having status positive or not by corona virus among the four groups. in the severe disturbance group, most of the child's parents were graduated family lived in the urban areas ( . %). the child had higher mental health disturbance scores who had higher corona positive relative/ neighbor [ table ]. [ table here] the result also showed that there was a significant difference in parents needed to go to the workplace or not, any chance of losing the job, and did smoke or not among the four groups. higher the number of parents of the child needed to go to the workplace ( %), had a smoking habit ( . %) and had the chance of losing their job ( . %) higher the score of depression, anxiety, and sleeping disorder of child. the score was also found higher for the child who fights frequently with each other, child who watched the cartoon and played the game - hours using a smartphone or other electronic device in a day, child whose parents didn't take any action to keep them busy, child who complained their parents remained busy, child whose parents called them by name that they (children) didn't like, child whose parents threatened them to be punished, child whose parents screamed and hit them (child) during the home-quarantine period [ table ]. the average score of depression, anxiety and sleeping disorder by different groups are presented in figure and it can be seen that the average score of depression, anxiety, and sleeping disorder of child is increased gradually from subthreshold disturbance group to sever disturbance group [ figure coefficients may also be interpreted. [ figure here] the chi-square test of the model fit yielded a value of . , with degrees of freedom= , p-value< . the results of chi-square test, rmsea = . , cfi = . , and tli= . . signaling that the model is well-fitted to data and hence, it is concluded that the assumed model is correct. the results disclosed that the child mental health is affected by the parental mental health as well as parents' attitudes towards child. the results are presented in figure and table . [ table here] [ figure here] mental health is an essential part of any country and ignored particularly in low and middle-income countries (patel, ) . bangladesh is a relatively small country according to area however having huge population with inadequate mental health care facilities for children and most hospitals use outpatient services. the largest part of the respondents was aged between to years and most of them were living in the urban areas and majorities are males ( table ). in this study, children's mental health (depression, anxiety, and sleeping disorder) scores were classified into four groups: sub-threshold, mild, moderate, and severe disturbance. the highest percentage of children are suffering from sub-threshold disturbance ( %), and . % had mild disturbances, . % had moderate disturbances, and . % had severe disturbances ( table ). the education level of parents of children, place of living, relatives/neighbors infected with covid- , still need to go to the workplace of parents, the chance of losing jobs of parents, the smoking habit of parents, hours watching the cartoon by children, children playing games, child fight, keeping busy with other works, acting of the child, children complain about parent's busyness, parent's abnormal behavior to children (call dumb, threat, scream, hit the child), and parent's knowledge about child abuse were significantly associated with children mental status ( table ) . children who live in urban areas with their parents were more prone to suffer mental healthrelated problems as compared to the rural area's child. perhaps the reason behind this scenario is that the lockdown was perfectly maintained in urban areas and children were forced to stay home anyway (the business standard, ). on the contrary, children in rural areas are free to move and can play with their relatives/friends (ranscombe, ) . children brought up in a rural environment, encompassed by animals and bacteria, grow stronger immune systems and might be at minor risk of mental illness than without pet-city inhabitants, as indicated in a study (hindustan times, ). usually, educated parents remain busy with their jobs as compared to uneducated ones even during this lockdown period in bangladesh, especially the government officials . as a result, they cannot manage time to communicate with their children as they demand. a bunch of social and personal adjustments is necessary to cope with this situation (poduval & poduval, ). if the work time of mother is longer, then the risks of children who are matured from one to five tended to increase child risks of experiencing psychological distress tended to increase the child risks of experiencing psychological distress as a young adult. the findings of this paper are also congruent with a previous study (poduval & poduval, ). parents who want to income more or who have higher family income need to give more time to their jobs or company even if they feel pressure to manage the company's activities like workers' activity, managerial team activity, and so on (mendez et al., ) . a longer period of part-time job mothers reduced the children's educational attainment and increase their child's mental distress but this effect was lower as compared to full-time employment mothers (saha et al., ) . in our study, it is also found that the children of higher-income parents are more likely to have mental disorders than others. parents who still need to go to the workplace and have a chance of losing jobs tended to increase the level of mental disorders of their children whereas it decreases for their counterparts. besides, parents whose feelings bored were tended to be more mental disturbances of their children as compared to their counterparts ( table ). the pressure that guardians bring home from their occupations can diminish their child-rearing abilities, sabotage the climate in the home, and in this way bring worry into kids' lives. moreover, children also feel pressure from their parents and becoming mentally sick (heinrich, ) . unfortunately, low-income parents are most apparent to work in stressful, lowquality jobs that prominence low pay, little autonomy, inflexible hours, and few or no benefits (heinrich, ) . it is well known that there is a strong association between a parent's smoking habits and child development behavior. since cigarette smoking is additionally connected with sadness, there are numerous unanswered inquiries regarding the interrelationship of these mental issues of children (shimomura et al., ) . the findings of this study also showed that parental depression and smoking behavior also linked to child mental disorder ( table ) . the children's mental depression was relatively low who was busy with some works as compared to who was not ( table ) , which is very usual. engaging with some works or encouraging daily exercise will help children to reduce depression (hurley, ) . children, who fight with others and get threats, scream and hit from their parents were much mentally disordered and increased severe mental disturbances as compared to their counterparts. because paternal and maternal behavior have an adjustment to children's mental health (elgar et al., ) . parents who threats, scream, or hit to their children are depressive and these depressive symptoms of parents and emotional behavior affect the child's mental health (gutierrez-galve et al., ) . again, children who act normal were in less mental disturbances as compared to others where the percentage increased gradually from less mental disturbances to severe mental disturbances. because if the children's sadness becomes interferes with social activities or regular life, it indicates that he or she has a depressive illness (lima et al., ) . this research has some limitations. firstly, considering health threats, a face-to-face interview was avoided whereas compared to face-to-face interviews, self-reporting has certain limitations. secondly, this study did not track the efficacy of psychological services as a cross-sectional study. finally, it would be better to have a larger sample size to validate the results but due to the current situation, it was not possible to collect samples on a large scale. the results demonstrate that large proportions of children are suffering from mental health disturbances in bangladesh during the lockdown period. mothers', as well as fathers' ability to forestall their emotional pain or manifestation of depression from influencing their role as a parent, might be a significant source of resilience for their children. the vulnerable cohorts for this study are children with the urban areas, higher educated parents, both higher and lower family income, smoking status (yes), parental depressive symptoms (threat, scream, hit, etc.), and the abnormal acting of the child. implementation of proper psychological intervention strategies and improvement in house-hold financial conditions, literacy of parents, taking proper care of children, and increasing job security and flexibility of parents may help in improving the psychological/mental status of children in bangladesh and the authors believe that the findings will be beneficial to accelerate the rate of achieving the sustainable development goals (sdgs) linked to public health in bangladesh. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. authors are grateful to all the participants who voluntarily offered their time, conscientiously provided honest and thoughtful responses and the personnel who supported data collection of this study. this study is considered a primary data set and the participants were given no economic motivation, and anonymity was maintained to make sure data confidentiality and reliability. it was also notified that at any time, participants could withdraw from the survey without giving any justification. the 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much mothers, and where is the womanhood? covid- : we can ward off some of the negative impacts on children rural areas at risk during covid- pandemic. the lancet infectious diseases survey reveals impact of lockdown on children status of mental health among left behind wives of migrant workers in north-east part of bangladesh association between problematic behaviors and individual/environmental factors in difficult children areas in dhaka under partial or complete lockdown fragile families and child wellbeing ten-year secular trends in sleep/wake patterns in shanghai and hong kong school-aged children: a tale of two cities mitigate the effects of home confinement on children during the covid- outbreak coronavirus disease (covid- ) covid- key: cord- -szll znw authors: serrano-ripoll, m. j.; ricci cabello, i.; jimenez, r.; zamanillo-campos, r.; yanez juan, a. m.; bennasar-veny, m.; sitges, c.; gervilla, e.; leiva, a.; garcia-campayo, j.; garcia-buades, e.; garcia-toro, m.; pastor-moreno, g.; ruiz-perez, i.; alonso-coello, p.; llobera-canaves, j.; fiol-deroque, m. a. title: effect of a mobile-based intervention on mental health in frontline healthcare workers against covid- : protocol for a randomized controlled trial date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: szll znw aim: to evaluate the impact of a psychoeducational, mobile health intervention based on cognitive behavioural therapy and mindfulness-based approaches on the mental health of healthcare workers at the frontline against covid- in spain. design: we will carry out a two-week, individually randomised, parallel group, controlled trial. participants will be individually randomised to receive the psycovidapp intervention or control app intervention. methods: the psycovidapp intervention will include five modules: emotional skills, lifestyle behaviour, work stress and burnout, social support, and practical tools. healthcare workers having attended covid- patients will be randomized to receive the psycovidapp intervention (intervention group) or a control app intervention (control group). a total of healthcare workers will be necessary to assure statistical power. measures will be collected telephonically by a team of psychologists at baseline and immediately after the two weeks intervention period. measures will include stress, depression and anxiety (dass- questionnaire - primary endpoint), insomnia (isi), burnout (mbi-hss), post-traumatic stress disorder (dts), and self-efficacy (gse). the study was funded in may , and was ethically approved in june . trial participants, outcome assessors and data analysts will be blinded to group allocation. discussion: despite the increasing use of mobile health interventions to deliver mental health care, this area of research is still on its infancy. this study will help increase the scientific evidence regarding the effectiveness of this type of intervention on this specific population and context. impact: despite the lack of solid evidence about their effectiveness, mobile-based health interventions are already being widely implemented because of their low cost and high scalability. the findings from this study will help health services and organizations to make informed decisions in relation to the development and implementation of this type of interventions, allowing them pondering not only their attractive implementability features, but also empirical data about its benefits. the current covid- pandemic is posing unprecedented challenges for health systems and healthcare workers (hcws) alike. worldwide, hcws are facing increased workloads, are at high risk of infection (for themselves and their cohabitants) [ ] [ ] [ ] , and lack of resources to handle the situation. as a result of having to make decisions such as how to provide care for severely unwell patients with constrained or inadequate resources, or how to balance their own physical and mental healthcare needs with those of patients, they are suffering a moral injury . this extreme situation has important implications for hcw´s mental health . a recent systematic review examining the mental health problems among frontline hcws during viral epidemic outbreaks observed a high prevalence of acute stress ( %), anxiety ( %), burnout ( %), depression ( %) and post-traumatic stress disorder ( %). health services worldwide are implementing strategies to mitigate these psychological consequences, most of which are based on the provision of cognitive-behavioural therapy (cbt) (e.g. united states , france , italy , sierra leone ). however, there is still very limited empirical evidence about the effectiveness of available interventions to protect mental health of hcws during viral pandemics . mobile health (mhealth) interventions are rapidly gaining popularity because of their low cost, high scalability and sustainability features. recent trials have examined the efficacy of mhealth interventions addressing mental health problems, including suicide , schizophrenia , substance use disorders , and psychosis , among others . recent systematic reviews investigating the efficacy of standalone smartphone apps for mental health show that, although they have potential for improving mental health symptoms, the available evidence is still scarce and more rigorous trials are needed . mhealth interventions are well suited to help hcws to combat the adverse effects of working in such high-pressure situations for a prolonged time period for two reasons . first, they can address non-treatment-seeking behaviour (a common issue among hcws ), as they provide the opportunity to engage individuals in need of treatment timely and anonymously by providing portable and flexible treatment. second, they are delivered in absence of face-toface interactions, reducing the risk of infection for sars-cov- . however, their effectiveness in this specific context and population is largely unknown: as observed by a recent review , only % of the studies about mental health apps to assist hcw during covid- included empirical evaluation of the reported interventions. robust, large scale trials are, therefore, urgently needed to determine the extent to which mhealth interventions can improve mental health of frontline hcws. spain is the country with higher mobile phone use rates in the world, with % of users . on may of , spain reported the highest cumulative number of covid- infections among hcws around the world ( , infections -counting for % of all hcw infections worldwide) . the pandemic produced very severe consequence in spanish hcws' mental health, with around % of hcws presenting symptoms of posttraumatic stress disorder, % of anxiety disorder, % depressive disorder, and . % feeling emotionally drained . under is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint these exceptional circumstances, we received funding to develop and evaluate a cbt and mindfulness-based intervention using an mhealth, to protect mental health of spanish hcws attending the covid- emergency. this article describes the protocol for the psycovidapp trial. this protocol trial has been prepared in accordance with the standard protocol items: recommendations for interventional trials (spirit) guidelines . . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the aim of this study is to evaluate the effectiveness of a psychoeducational mhealth intervention against a control app intervention, to protect mental health in hcws at the frontline against covid- in spain. the specific objectives are: -to analyse the efficacy of the intervention (in the overall sample and in specific subgroups based on baseline mental health status and use baseline use of psychotherapy and psychopharmaceutical drugs) in reducing the levels of depression, anxiety, anxiety, acute and posttraumatic stress, burnout, self-efficacy, and insomnia. -to examine the usability of the intervention. we will carry out a blinded, two-weeks, individually randomised, parallel group, controlled trial. participants will be individually randomised with an allocation ratio of : to receive either the psycovidapp intervention or control app intervention (both described below). the trial will be carried out in healthcare centres in spain, including hospitals, primary care centres, and care homes. the trial will include male and female hcws aged> , who report having provided healthcare to patients with covid- during the viral outbreak in spain (from the onset of the health emergency to the recruitment time). for this study hcws will be defined as professionals regulated by a health system who deliver care and services whose primary intent is to enhance health. hcws from any medical speciality (pneumology, internal medicine, emergency, primary care, etc.) and role (doctors, nurses, nurse assistants, etc.) with access to a smartphone will be included. we will include hcws who have provided direct, face to face, healthcare to patients with a diagnosis of infection by covid- . this will include healthcare to any health problem patients may experience (i.e., not only caused by covid- ). we will exclude hcws with no access to a smartphone, or not able to download and activate the app used to deliver the intervention during the next days following the baseline assessment in their smartphone. hcws will be considered withdrawn from the study if they retire their consent to participate, or if they do not receive a postintervention evaluation within the next days after the end of is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the intervention period. reasons for withdrawals and discontinuation of any participant from the trial will be recorded. a flowchart describing the psycovidapp trial procedures is available in figure . we will send invitations to hcws to participate in the trial through social media and key stakeholders hospital managers and communication departments, trade unions of hcws, scientific societies, research institutes, private insurances companies, home care centres and professional colleges). hcws willing to participate will register their interest by completing an online questionnaire, which will contain a participant information sheet. a team of psychologists, who will have previously received a -hour training session (to ensure homogeneity in recruitment, questionnaire administration, and data entry methods), will contact via telephone with registered hcws to confirm eligibility criteria, to obtain informed consent (audio-recorded), to carry out a psychological (pre-intervention) evaluation, and to instruct participants about how to download the clinicovery© app (apploading, inc). clinicovery© is a platform that allows uploading information in multiple formats (text, video, audio) and organize it in modules . these modules are then made available to users of the clinicovery© app. this system has two main advantages that makes it ideally suited for its use in clinical trials: first, the access to the app contents remains under the control of the researchers, who individually activate the contents of the app after hcws have registered (i.e., users cannot access to the intervention with no activation from a member of the research team); second, it allows the researchers to allocate different contents to different groups of users (e.g., intervention and control groups). within hours after participants successfully download and activate the app (user activation of the app will be used as a checkpoint to ensure participants can successfully use it), a member of our research team will load the contents to the app according to the group participants have been allocated to. this procedure will ensure allocation concealment. during the next days, all hcws will continue with their usual care (e.g,. use of psychopharmaceutical drugs or psychotherapy, if any) throughout the study. in addition, the intervention group will have access to contents of the psycovidapp intervention (described below). participants in the control group will only have access to control app intervention (below). after two weeks, the contents uploaded in both groups will be disabled, and a postintervention psychological assessment will be undertaken via telephone. after the postintervention assessment, all participants will be offered free, unrestricted access to the psycovidapp intervention. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint we will randomize patients individually using a computer-generated sequence of random numbers. hcws will be blinded to group allocation. data analysts and outcome assessors (in this case, the psychologists who will undertake the pre-and post-intervention psychological evaluations) will also be blinded. the psycovidapp intervention was developed on may by a group of nine experts (five psychologists, two psychiatrists, and two experts in lifestyle modification), informed by findings from an exploratory qualitative study involving in-depth interviews with eight hcws seeking psychological support, as a result of their professional activity during the covid- pandemic (unpublished results). the intervention developers adhered to current recommendations for the development of mental health apps . the psycovidapp intervention aims to prevent and mitigate the most frequent mental problems suffered by hcws attending the current covid- emergency (depression, anxiety, stress, and burnout). the intervention includes psychoeducational components, and it is based on cbt and mindfulness approaches. the contents are grouped into five main sections (see box ): emotional skills, lifestyle behavior, work stress and burnout, social support, and practical tools. each section contains multiple modules, covering the following areas: i) monitoring mental health status; ii) educational materials about psychological symptoms (e.g. anxiety, worry, irritability, mood, stress, moral distress, etc.); iii) practical tips to manage pandemic-related stressors (e.g., is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint mindfulness, relaxation and breathing techniques, coping strategies, survival skills to emotional crises); iv) healthy lifestyles and practical tips to promote them; v) organizational and individual strategies to promote resilience and reduce stress at work and the burnout syndrome, and; v) promotion of social support. the contents are displayed using written information, audios and videos (see figure ). additional information is offered through links to web pages, articles, guides, videos and audios. all these contents will be permanently available during the -week intervention period. additionally, the intervention includes temporal modules, which are available only for hours. each day the users will be prompted by a notification indicating that a new message is available. these messages contain a brief question followed by a short message. the messages have specific purposes, including: monitoring of mental health status, invitation to practice, reminders, and encouragement. the majority of the temporal modules offer tailored information or recommendations based on users' responses to the brief questions ( figure ). box . description of the content of the psycovidapp intervention  section . emotional skills  knowing and identifying the most common emotional reactions that hcws may experience during or after the covid (depression, anxiety, acute and post-traumatic stress, and burnout)  introduction to mindfulness and audios to start its practice.  emotional regulation: strategies and practical advice (e.g., relaxation exercises through breathing or imagination, jacobson's progressive relaxation, etc.)  tips and tools to improve a period of crisis and/or emotional blunting. section . lifestyle behavior  information on healthy lifestyle (i.e., physical activity, diet, exposure to sunlight, sleep and non-consumption of alcohol and tobacco) and its relationship with psychological well-being  self-assessment of a healthy lifestyle  tips to encourage support of healthy lifestyle behaviors. section . work stress and burnout  informative content about work stress and burnout  practical advice to learn how to handle and prevent work stress and burnout. section . social support  web resources to deepen the concept of social support and its different types  tips to promote social support and integrate it into the own code of social behavior. section . practical tools  compilation of all the practical tools presented in the previous modules is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint participants in the control group will have access through the clinicovery© app to a control app intervention (see figure ) . this intervention will only include brief written information, adapted from a set of materials developed by the spanish society of psychiatry for mental healthcare of hcws during the covid- pandemic. the information is organized in three sections: challenges faced by hcws during the covid- pandemic; common reactions to intense stress situations, and; mental health self-management recommendations. no temporal modules will be available for the control intervention. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the primary outcome will be the difference between the intervention and control groups in the mean overall score the depression, anxiety and stress scales (dass ) instrument . the score ranges from (worst outcome) to (best outcome). the instrument contains three items scales, assessing presence and intensity of depression, anxiety and stress. items are based on a likert-scale ranging from - points. secondary outcome measures will be the difference between intervention and control groups in the mean scores of the following instruments: . the dts is a -item, likert-scale, self-report instrument that assesses the dsm-iv symptoms of post-traumatic stress disorder. both a frequency and a severity score can be determined. the dts yields a frequency score (ranging from to ), severity score (ranging from to ), and total score (ranging from to ). higher scores are indicative of a worse outcome. the scope of the questionnaire to capture only post-traumatic stress disorders related with the covid- health emergency.  maslach burnout inventory -human services survey (mbi-hss) . the mbi-hss is a item, likert-scale, self-reported instrument that assesses three domains of burnout: emotional exhaustion ( items), depersonalization ( items) and personal achievement ( items). all mbi items are scored using a -level frequency scale from "never" to "daily." each scale measures its own unique dimension of burnout. scales cannot be combined to form a single burnout scale.  insomnia severity index (isi) . the isi is a -item, likert-scale, self-reported instrument assessing the severity of both night-time and daytime components of insomnia. scores range from (best outcome) to (worst outcome). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint  general self-efficacy scale (gse) . the gse is a -item, likert-scale, self-reported instrument that assesses optimistic self-beliefs to cope with a variety of difficult demands in life. scores range from (worst outcome) to (best outcome).  system usability scale (sus) . the sus is a -item, likert-scale, self-reported instrument assessing subjective assessments of usability. it comprises three domains: effectiveness (whether users can successfully achieve their objectives); efficiency (how much effort and resource are expended in achieving those objectives); and satisfaction (whether the experience was satisfactory). scores range from (worst outcome) to (best outcome). it is estimated that participants ( per group, allowing for % attrition) will be required to detect at least an effect size of . (cohen´s d) on dass with % power and alfa of % (one-sided). the primary statistical analysis will be carried out on the basis of intention-to-treat (itt) (i.e. all participants that agreed to participate will be included in the analysis according to the group to which they were assigned). the study results will be reported in accordance with the consort statements and a full detailed statistical analysis plan will be prepared before recruitment starts (including any interim, subgroup and sensitivity analyses). differences between groups of primary and secondary outcomes will be analysed using general linear modelling (ancova) for continuous variable, adjusted by baseline score. the results from the trial will be presented as regression coefficient for predicting change in primary and secondary outcomes with % confidence intervals. we will use multiple imputation by chained equations (mice) to fill in missing values ( imputation sets) . we will carry out subgroup analyses to examine the impact of the psycovidapp intervention on primary and secondary outcomes according to groups of hcws based on the following baseline characteristics: use of psychopharmaceutical drugs (yes vs. no), use of psychotherapy (yes vs. no), and symptomatology of depression, anxiety, stress (yes vs. no -based on baseline dass- median score). research ethical committee approval was obtained by the research ethics committee of the balearic islands (cei-ib ref no: ib / pi). all potential participants submitting their expression of interest to participate in the study will receive a participant information sheet. an audio-recorded informed consent will be obtained from every participant before data collection via telephone. hcws will be informed of freedom to withdraw at any time and will be assured of anonymity by using special code numbers to identify themselves. all of the collected data will be pseudo-anonymized and kept confidentially. only members of the research team will be able to re-identify the participants. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint validity and reliability this study uses a rigorous research design, an rct with a representative and predetermined sample. it uses instruments with a high validity and reliability, and statistically analysis, which can be seen to reduce bias effectively and enhance the generalizability of research results beyond the target population. moreover, trial participants, outcome assessors and data analysts of the research will be blinded to intervention allocation to reduce the biases in the evaluation of the effects of the intervention. the study design, procedures and reporting will follow the consort statement recommendations on randomized controlled trials . an additional strength of this study is that it will be performed under routine clinical conditions, and with a broad range of hcws. this feature will give strong external validity. the global health emergency generated by the covid- pandemic is posing an unprecedented challenge to frontline hcws, who are facing high levels of workload under psychologically difficult situations with scarce resources and support. there is a growing interest in the use of digital technology to deliver mental health care. however, this area of research is still in progress, and rigorous trials are needed to determine the extent to which these interventions can produce the desired benefits. this study will evaluate a psychoeducational mental health app based on cbt and mindfulness approaches, specifically developed to meet the needs of hcws during the covid- pandemic. this study will help to increase scientific evidence regarding the effectiveness of this type of intervention on this specific population and context. mhealth interventions are already being widely implemented because they are low cost, sustainable and highly scalable, but in absence of solid evidence about its effectiveness. the findings from this study will help health services and organizations to make informed decisions in relation to further development and roll out of this type of interventions, allowing them to ponder not only their attractive implementability features, but also providing robust data on impact on mental health. the study has also some limitations. first, the two weeks follow-up period may be not enough to detect clinically meaningful differences in the selected outcomes. although adherence to mhealth apps generally decrease overtime , and two weeks is enough to access to all the contents of the psycovidapp intervention, a longer period of time may be needed to produce the desired positive effects on mental health. second, restricting the study to hcws with a smartphone and able to download and use mobile apps may cause a selection bias which could reduce the generalizability of our results. this is a common limitation of mhealth trials, and which is unlikely to significantly affect the results of our study, since spain is currently the country with higher smartphone use rates in the world, with % of users .third, the mental health of the participants will not be evaluated through a clinical interview, but rather using instruments indicated for symptomatology assessment rather than for clinical diagnosis. fourth, we will not restrict our sample to hcws with mental health problems at baseline. including a large proportion of participants with no (or minor) mental health problems in our study may limit our ability to observe mental health improvements. fifth, high dropout rates . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint and low intervention adherence are common limitations of trials of low-intensity interventions, such as the one proposed in our study. sixth, our ability to conduct the planned subgroup analyses may be limited by the size of such groups. seventh, it is worth noting that this trial will be undertaken during a very specific and rapidly evolving context: the covid- pandemic. therefore, rapid recruitment of hcws will be needed to ensure the intervention is homogeneously tested in the same context. although we will allocate resources to recruit through hospitals, professional and scientific societies and hcws unions, the feasibility of such rapid recruitment has not been previously examined. finally, we will not be able to monitor the level of use of the app during the trial, and therefore it will not be possible to determine the extent to which higher intervention adherence is associated with higher benefits on mental health. this research will study for the first time the impact of a psychoeducational cbt-and mindfulbased mhealth intervention specifically designed to protect mental health of frontline hcws fighting against the covid- pandemic in spain. the findings from this study will be used to inform decisions about wider rollout of the psycovidapp intervention immediately after the trial. in addition, the study findings will help increase the scientific evidence concerning the impact of mental mhealth interventions on a specific population (hcws) under a specific context (the health emergency caused by the covid- pandemic); as well as, more generally, the evidence about the effectiveness of mhealth-an area of research still in its early stages, for which robust trials are urgently needed. professional quality of life and mental health outcomes among health care workers exposed to sars-cov- (covid- ) mental health consequences of covid- : the next global pandemic psychological status of medical workforce during the covid- pandemic: a cross-sectional study managing mental health challenges faced by healthcare workers during covid- pandemic impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis mount sinai's center for stress, resilience and personal growth as a model for responding to the impact of covid- on health care workers battle buddies: rapid deployment of a psychological resilience intervention for health care workers during the covid- pandemic psychological support system for hospital workers during the covid- outbreak: rapid design and implementation of the covid-psy hotline promoting resilience in the acute phase of the covid- pandemic: psychological interventions for intensive care unit (icu) clinicians and family members. psychological trauma : theory, research, practice and policy effectiveness of small group cognitive behavioural therapy for anxiety and depression in ebola treatment centre staff in 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: a scoping review symptoms of posttraumatic stress, anxiety, depression, levels of resilience and burnout in spanish health personnel during the covid- pandemic spirit statement: defining standard protocol items for clinical trials mental health smartphone apps: review and evidence-based recommendations for future developments psycometric properties of the spanish version of depression, anxiety and stress scales (dass) instrumentos básicos para la práctica de la psiquiatría clínica: barcelona: psiquiatría editores, sl factorial validity of the maslach burnout inventory (mbi-hss) among spanish professionals validation of the insomnia severity index as an outcome measure for insomnia research psychometric properties of the general self efficacy- scale in spanish: general and clinical population samples an empirical evaluation of the system usability scale statement: updated guidelines for reporting parallel group randomised trials multiple imputation by chained equations (mice): implementation in stata barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence we thank the hcws who participated in the individual qualitative interviews to inform the design of the psycovidapp intervention. key: cord- -z l tsir authors: johnson, sonia; dalton-locke, christian; vera san juan, norha; foye, una; oram, sian; papamichail, alexandra; landau, sabine; rowan olive, rachel; jeynes, tamar; shah, prisha; sheridan rains, luke; lloyd-evans, brynmor; carr, sarah; killaspy, helen; gillard, steve; simpson, alan title: impact on mental health care and on mental health service users of the covid- pandemic: a mixed methods survey of uk mental health care staff date: - - journal: soc psychiatry psychiatr epidemiol doi: . /s - - - sha: doc_id: cord_uid: z l tsir purpose: the covid- pandemic has potential to disrupt and burden the mental health care system, and to magnify inequalities experienced by mental health service users. methods: we investigated staff reports regarding the impact of the covid- pandemic in its early weeks on mental health care and mental health service users in the uk using a mixed methods online survey. recruitment channels included professional associations and networks, charities, and social media. quantitative findings were reported with descriptive statistics, and content analysis conducted for qualitative data. results: , staff from a range of sectors, professions, and specialties participated. immediate infection control concerns were highly salient for inpatient staff, new ways of working for community staff. multiple rapid adaptations and innovations in response to the crisis were described, especially remote working. this was cautiously welcomed but found successful in only some clinical situations. staff had specific concerns about many groups of service users, including people whose conditions are exacerbated by pandemic anxieties and social disruptions; people experiencing loneliness, domestic abuse and family conflict; those unable to understand and follow social distancing requirements; and those who cannot engage with remote care. conclusion: this overview of staff concerns and experiences in the early covid- pandemic suggests directions for further research and service development: we suggest that how to combine infection control and a therapeutic environment in hospital, and how to achieve effective and targeted tele-health implementation in the community, should be priorities. the limitations of our convenience sample must be noted. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. been launched, there has been less focus on the needs of people already living with mental health conditions, and on how mental health services are supporting them at a time of potential staff shortages and service reconfigurations [ ] . potential risks to provision of mental health care worldwide include staff absences due to sickness and the need to self-isolate, and workforce redeployment, for example from community to inpatient settings. in the community, staff in many countries have been required to limit face-toface contacts to essential tasks such as the administration of injectable medication [ ] . beyond the immediate changes to services seen in the early stages of the pandemic, there are many potential challenges that are specific to mental health care. these include difficulties in implementing infection control and social distancing guidance in settings where people may be very distressed or cognitively impaired [ ] , especially in mental health wards and the supported accommodation settings where many people with complex mental health problems live [ ] . face-to-face meetings are usually central to mental health care: severe restrictions to this seem likely to greatly alter staff and service user experiences. there is also a considerable risk that, even after restrictions are lifted, there will be a lasting exacerbation of health and social inequalities that affect people with longer term mental health problems, for example, through increased economic disadvantage, inequalities in health care, or sequelae of increased trauma and abuse [ , ] . since the start of the pandemic, experts from around the world have published views about potential negative impacts of the pandemic on mental health services [ , , ] and the suggestion has also been recurrently made that it could provide an opportunity for positive service developments [ ] [ ] [ ] . however, there is a lack of research directly assessing and reporting the experiences and perspectives of those currently working in the mental health system. our aim was to inform further research and service responses by conducting, in the early stages of the covid- pandemic, a survey of the perspectives and experiences of staff working in inpatient and community settings across the uk health and social care sectors. the king's college london research ethics committee approved this study (mra- / - ) , which involved mental health staff in the uk completing an online questionnaire. in the absence of a measure of pandemic impact on mental health care and mental health service users, we rapidly developed an online questionnaire to collect cross-sectional quantitative and qualitative data from mental health care staff. all staff working in face-to-face mental health care in the uk, or managing those who provide such care, were eligible to participate. all specialties were included, as were nhs, private healthcare, social care, and voluntary sector services. the lead developer of the questionnaire, sj, an academic and practising inner london psychiatrist, read key sources identified in an accompanying rapid review of relevant literature [ ] , including academic and professional journals, news media, and organisational websites, and followed relevant social media topics. the drafting of the questionnaire was further informed by the nihr mental health policy research unit (pru) working group for this study (about people, including clinicians, researchers, and people with relevant lived experience), and the pru lived experience working group. both groups discussed the study at online meetings and identified important topics for inclusion. nine further clinicians provided email summaries of the challenges which they were currently facing and how they were being addressed. feedback was obtained from the pru working group on a first draft of the questionnaire, together with additional input from experts in fields including mental health care for older people, children and adolescents, people with drug and alcohol problems, offenders, and people with intellectual disabilities. the questionnaire was revised and converted into an online format using the ucl opinio platform. pilot testing was then conducted with clinicians, who provided feedback on length, acceptability, and relevance, and on problems with specific items. following this, a final version of the questionnaire was agreed. a mixture of structured and open-ended questions was included. participants were asked which sector and region they worked in but not which organisation, maximising anonymity. participants could skip questions if they wished, and internet cookies were used to prevent participants completing multiple questionnaires. a branching structure was adopted, with initial questions asking all participants to rate the relevance of each item on lists of: -challenges at work during the covid- pandemic. -problems currently faced by mental health service users and family carers (from a staff perspective). -sources of help at work in managing the impact of the pandemic. this was followed by sections for staff in specific settings and specialties. questions also elicited details of adaptations and innovations introduced to manage the impact of the pandemic, and their perceived success, and enquired about concerns for the future and any aspects of current practise that they would like to keep after the pandemic. participants were asked between and questions depending on their eligibility for branching questions for specific settings or specialties. depending on the detail provided to open-ended questions, the survey typically took - min to complete. a copy of the survey is available at this web address: https ://opini o.ucl.ac.uk/s?s= . our aim was to achieve rapid recruitment of a large and varied sample by dissemination through multiple channels including: in the final week of recruitment, we targeted under-represented sectors, including relevant voluntary sector organisations and supported housing providers. we also sought to increase representation of staff from black, asian, and minority ethnic groups by focused social media recruitment via the mental elf, including a video in which a prominent black psychiatrist encouraged participation, and contact with the networks of pru researchers who work on issues of diversity. quantitative data: we aimed to give an overview of the impact of the pandemic. we produced descriptive statistics using stata to summarise relevant aspects of the quantitative data. missing data are reported in the footnotes of the relevant tables in the supplementary report. qualitative data: qualitative analysis was conducted to expand on quantitative findings [ ] . a preliminary analytical coding framework was developed by sj guided by the study research questions, quantitative analysis results, and themes emerging from the initial survey responses. the responses to open-ended questions were left unedited and compiled under topics relevant to the research questions. coding matrices were developed in microsoft excel, with the emerging codes in the columns and cases in rows. directed descriptive content analysis was then conducted [ , ] . for this, all survey responses were indexed in the coding matrices by a group of researchers, mostly phd students or researchers with relevant lived experience. topics that came up repeatedly in the data and could not be categorised with the initial coding framework were given a new code. coding work was coordinated by so (associate professor) and nvsj, uf, and ap (post-doctoral researchers) to increase consistency and accuracy when applying the predetermined codes, and to discuss adding codes to the initial framework when necessary. sj and as (clinical professors) helped to understand clinical contexts and resolve coding difficulties. finally, the coding team developed summaries of each code and presented these in tables ranked in order of frequency, shown in the supplementary report. involvement of this large team allowed us to complete analysis within weeks. we summarise key findings here: our accompanying supplementary report gives much more detail. data were collected from april to may . in total, , people started the survey (including many who clicked 'start' but provided no or minimal data) and , got to the end. we report results for participants who completed at least one question from each of the three main sections open to all respondents. this produced a sample of , . there were , responses to open-ended items, yielding , words for rapid qualitative content analysis. a large majority of participants worked in the nhs ( , , . %). approximately a third described themselves as nurses ( , . %), as psychologists ( . %), as psychiatrists ( . %), as social workers ( . %), and as peer support workers ( . %). over a third identified as a manager or lead clinician in their service ( , . %). over two-thirds worked with working age adults ( , , . %), . % worked with older adults ( ), just under a third worked with people with learning disabilities ( , . %), around a fifth worked with people with drug and alcohol problems ( , . %), and another fifth worked with people with eating disorders ( , . %). participants could report working with multiple service user populations and/or in multiple settings. the majority worked in england ( , , . %) with around a third of these based in london ( , . %) and a fifth in the north west ( , . %); three-quarters worked in cities or towns with populations greater than , ( , , . %). four-fifths were female ( , , . %) and almost nine-tenths were from white ethnic groups ( , , . %). full demographic details, including age, caring responsibilities, and covid- status, can be found in table x of the supplementary report (references to tables in the supplementary report are herein indicated with an 'x' after the table number to distinguish them from tables in the main text). participants rated a list of current challenges at work, some general and others setting-specific, on a five-point scale from 'not relevant' to 'extremely relevant'. table shows the five work challenges rated highest in each type of setting; tables x- x report this in further detail. in inpatient wards and crisis houses, infection control challenges, related to table top five rated work challenges* for each setting (see tables x- x and x- x in the supplementary report for further details) * includes 'current work challenges' (c) asked of staff from all settings and 'additional work challenges' (a) that are specific to each service type ** a respondent may work in more than one setting (e.g., an inpatient service and a crisis assessment service), but will provide only one answer per challenge *** the 'additional work challenges' (a) sections, which are specific to specific settings and specialties, appear in the survey after the 'current work challenges' (c) section, which is open to staff from any setting. therefore, the reduced n for a challenges compared to c challenges represents respondents who completed the first sections of the survey, but then did not go on to complete the later branched sections of the survey both service users and staff becoming infected, were rated highest, alongside increased boredom and agitation amongst service users due to lack of activity and contact on the ward. crisis service staff rated as most relevant lack of services to which they could refer on or signpost. community team staff rated items related to changes in ways of working and adoption of remote technologies highest, along with reduced availability of other services. the small group of residential service participants gave a high relevance rating to their environment being more challenging, because residents cannot go out and/or engage in usual activities. table x shows ratings by profession and table x shows ratings by managerial roles. there were fewer obvious differences by profession than by setting, but managers and lead clinicians more often reported challenges relating to supporting colleagues with stressors due to the pandemic, and increased workload during the pandemic as very or extremely relevant ( . % and . %, respectively) compared to those not in these roles ( . % and . %, respectively). half of staff in inpatient and residential settings reported that they could not consistently follow the rules set on infection control ( , . %), and just over a third reported that they could not do this in community and other settings ( , . %). table shows the impediments to this most often identified from qualitative content analysis of responses, with more detail in tables x- x. tensions between meeting clinical needs and infection control were reported across settings, for example in responding to emergencies on wards or when service users in the community needed home visits, on which infection control measures were very difficult to implement. the built environment was the most frequently cited challenge in the community, and ward layouts impeded infection control in hospital. in each setting, there were also reports of conflicting or unclear guidance. reports of not having the facilities and processes to adhere to guidance, for example in putting on and disposing of personal protective equipment (ppe), were especially prominent in the community. unclear or conflicting guidance and procedures, and service users who are unable to understand and adhere to infection control rules, were reported across settings. substantial numbers were also concerned about perceived conflicts between protective equipment and therapeutic relationships, for example when trying to engage service users with paranoid ideas while wearing a mask. we also asked participants to report, if data were available to them, the extent of activity change in the service in which they worked (table x ). responses varied, but reports of reduced activity considerably exceeded those of increased activity, especially regarding inpatient admissions (though less so for compulsory admissions) and new referrals to crisis services and community services. however, in community services, including psychological treatment services, similar numbers of staff said that they were having more weekly contacts as said they were having fewer. table summarises staff perceptions of the current relevance of various types of difficulty for the service users and carers with whom they were in contact (table x reports this in greater detail and by service user group). across all groups, staff tended to rate social difficulties as most relevant, for example, loneliness and lack of usual support from table top five reasons infection control rules could not be followed for inpatient and community settings* (with frequencies), responses to an open-ended question (see tables x- x in the supplementary report for further details) * a respondent may work in more than one setting (e.g., an inpatient service and a crisis assessment service) ** includes staff working in inpatient services, crisis houses, and residential services *** includes staff working in crisis assessment services, community teams and psychological treatment services, community groups, and other settings inpatient and residential settings** community settings*** family and friends. several other types of problem were also rated by many staff as very or extremely relevant, including lack of normal support from mental health and other services, deterioration in mental health in the pandemic period, worries about infection, and being at high risk if infected. responding to open-ended questions, staff identified a range of groups of service users about whom they were particularly concerned, some because of impacts on their clinical condition, others because of their social characteristics or circumstances, or because of specific difficulties providing an adequate service for them. table summarises groups frequently identified as of particular concern, and table x gives more detail. we also asked staff whether they were seeing people with mental health difficulties that appeared to arise from the pandemic (table x) . some described symptoms directly related to covid- , such as delusional beliefs regarding covid- infection or quarantine, and health anxiety or obsessive-compulsive symptoms related to infection. others described relapses in people who had long been stable that they felt were linked to the stresses of the crisis. some also reported apparently first presentations of mental health problems such as psychosis or mania among healthcare workers. table summarises responses to a question about which sources of help were currently most important to staff in managing the impact of covid- at work. across all professions, the most important sources of help were support and advice from employers, colleagues, and managers, closely followed by new digital ways of working and the resilience and coping skills of service users and carers, the latter presumably seen as making the crisis less burdensome for staff, at least at its onset. patterns of response were not markedly different across professional groups (tables x- x). table summary of staff perspectives on which of their service users' and carers' problems are most relevant, in order of % rated very or extremely relevant (n = , ) (see table x participants in crisis and community services were asked whether services they worked in had changed opening hours or locations, and how their practices had changed (table x ). services that had increased their hours during the crisis, for example with weekend opening, were described, as well as reductions in other services. most staff working in crisis services reported that home visits were continuing when strictly necessary. a mixture of responses was obtained from community services (including both community mental health teams and psychological treatment services), with some reporting continuing face-to-face contacts and home visits as needed, others having stopped them. responses regarding psychological treatment were split between aiming to provide a full table frequently cited examples of the groups of service users about whom staff participants have been especially concerned during the pandemic: qualitative content analysis of open-ended responses (see table x in the supplementary report for further details) people who are cognitively impaired (e.g., due to dementia or learning disability), who may find situation hard to understand and struggle to follow guidance people with psychotic symptoms that may be exacerbated by current events and interfere with their ability to follow guidance people with complex emotional needs (who may have a "personality disorder" diagnosis), who may be destabilised by abrupt loss of support and routines; people with anxiety or ocd, especially those for whom covid- interacts with contamination-related symptoms women with perinatal mental health problems, lacking usual support and assessment around the time of birth people with drug and alcohol problems, for whom treatment and support are often severely disrupted and following guidance may be difficult people with eating disorders, at risk from disruption to usual eating, exercise, and social routines and to food access people of concern due to impacts related to social circumstances or characteristics people who live alone/are currently socially isolated and lonely older people with mental health problems, due to loss of usual support (e.g., family visits) and additional physical health vulnerability people who are in households where there is domestic violence or conflict children in homes that may not be safe or where there is family conflict people living in poverty/poor housing, or who are homeless, for whom the lockdown is especially difficulty people of particular concern due to service disruptions inpatients who have experienced service disruptions, including precipitate discharge, delayed discharge because of infection concerns, lack of leave or visits, and increased isolation and lack of activity or therapies on the wards people who are difficult to reach in the community without usual visiting/outreach/face-to-face appointments and may not be seeking help that is needed people at risk because of disrupted availability of medical responses, e.g., for people who harm themselves and are discouraged from visiting/ reluctant to visit emergency departments open-ended questions elicited adaptations and innovations made to manage the impact of the pandemic (table x ). the most widely reported shift was greatly increased adoption of remote technologies, as discussed below. some participants also reported adopting new digital tools for assessment and therapy, such as apps and websites. other innovations included new crisis services, such as crisis assessment centres rapidly established as alternatives to hospital emergency departments and new crisis phone lines, and re-organised services, resulting in extended hours, increased access for specific groups, or shorter waiting lists (e.g., for psychological treatment). reported changes in the types of help offered included community services arranging practical help, such as food deliveries for service users, and providing resource packs to help service users to be active at home. also frequently described were new or expanded forms of support for staff, including 'wobble' rooms (quiet rooms for staff who feel overwhelmed), staff helplines, increased supervision, wellness check-ins, and more use of informal support mechanisms. also reported was a general shift towards a more flexible approach, reducing bureaucracy and removing barriers to change, leading to a more agile way of working and a more responsive service. many staff also valued the many benefits to their well-being, productivity and efficiency in being able to conduct some of their client contact or administrative tasks away from the office. further quantitative and open-ended questions explored views and experiences of the shift to remote working (tables x- x) . almost all staff in community services ( , , . %) , and a large majority in crisis services ( , . %), were replacing some face-to-face contacts with phone or video calls. the shift to video calls did not appear to have been very extensive, however, with the majority ( , . %) reporting use of this technology as their main means of contact with % or fewer of the service users with whom they have contact. views about this were mixed. video calls for communication between staff attracted the greatest enthusiasm, with more than two-thirds ( , . %) from both community and crisis services agreeing or strongly agreeing that they are a good way to hold staff meetings; this was echoed in open-ended questions. a majority ( , . % of respondents to this question) agreed or strongly agreed that video calls were a good way to assess progress of some people already known to the service, but only . % ( ) agreed or strongly agreed that they can be a good way of making the initial assessments. responses to open-ended questions ( table , tables x- x) likewise identified concerns about being able to make a good assessment remotely, as well as about forming rapport: they tended to suggest digital technologies were useful for clients with less complex needs, for "light-touch" interventions or for low-intensity therapeutic approaches and follow-up appointments. a majority ( , . %) agreed or strongly agreed that use of remote rather tables x- x in the supplementary report for further details) what's working well in tele-health what can prevent tele-health from working allows prompt responses saves travelling time is better for the environment may be more convenient for both staff and service users allows staff to connect easily with each other, even if based in different places and different teams allows home working best alternative for now: remote working is allowing services to keep going despite infection control restrictions innovative use of it and digital tools can allow group programmes or individual therapies to continue successfully benefits for some clients: some clients are happy with video-call technology and even prefer it access is improved for some people, especially if travel and public places are challenging may be an efficient way of helping people with less complex needs inadequate resources: equipment and internet connections of low quality processes and preferred platforms not clearly established staff may lack training and confidence impacts on communication and therapeutic relationships may be harder to establish and maintain a good therapeutic relationship may be harder to make an assessment, especially at first contact may be challenging for longer, more in-depth sessions digital exclusion: people who lack equipment and resources to connect people who don't have skills or confidence to connect (including people with cognitive impairments) people lacking a suitably private environment for remote appointments service user preferences: some service users strongly prefer confidential conversations to be faceto-face, or may feel suspicious or anxious about remote means if they do accept remote contacts, some prefer simpler phone or messaging modalities some service users do not engage with remote contacts than face-to-face consultations had resulted in not having contact with some service users who had not engaged with remote appointments. two-thirds ( . %) answered yes when asked whether they wished to retain longer term any changes made during the pandemic. table x summarises responses. a large majority involved keeping some aspects of remote working, with many feeling that selective use of technology platforms to connect staff with each other and with service users has potential long-term benefits for efficiency and the environment, particularly if technical difficulties are resolved and appropriate protocols developed. others wished to retain some new service initiatives, such as crisis centres in the community, or the increased flexibility and ease of making changes experienced at this time. responses to a question about concerns for the future were numerous and detailed (table x) . while many participants reported that referrals to their service had decreased in the early phase of the pandemic, many feared that need would increase significantly in future and that lack of capacity and staff burnout may impede response to this. anticipated drivers of increased future need included traumas, bereavement, and complex grief experienced by frontline staff, service users, and the wider public; mental health problems not managed effectively among people who have disengaged or not sought help during the pandemic; increased levels of domestic abuse and family conflict; and the effects of wider societal disruption and increased inequalities due, for example, to unemployment and homelessness. fears were also expressed that reduced levels of service might persist inappropriately after the current emergency period, that changes made in response to the crisis might be used to justify reduced funding in future, or that staff would be expected to continue with working patterns that they had agreed to only because of the crisis. extension of remote working beyond the circumstances in which it had proved helpful was a further concern. several respondents were concerned about the disproportionate impact of the pandemic on black, asian, and minority ethnic staff and service users, and about potentially increased racism and xenophobia. a wide range of challenges are reported by practitioners across the mental health sector, some specific to service settings or groups of service users and carers. while many commentators have predicted a significant and widespread impact of covid- , we are able to provide a more detailed report that is rooted in direct experience of the effects of the pandemic on mental health care, albeit only in one country and only from the perspective of practitioners. in the context of the pandemic, infection control is an immediate need whose complexity in mental health settings is a significant finding from our study. lack of ppe was sometimes identified as a problem. more prominent, however, were challenges relating to processes, to the physical environment in which mental health care is delivered, and to tensions between infection control requirements and providing safe care and maintaining therapeutic relationships with people who may be distressed, suspicious, or struggling to comprehend the situation. inpatient and residential services, and crisis services, where continuing face-to-face contacts appear more frequent than in routine care, are not surprisingly the settings in which staff are most immediately concerned with the spread of infection: the price of failure is potentially very high, as indicated by a recent care quality commission report on excess deaths related to covid- among people subject to the mental health act [ ] . the shift to remote working, strikingly rapid given that tele-health has been discussed over many years but with limited implementation, has been widely discussed; we examine staff perspectives on this in detail in the current study. both our quantitative and qualitative data suggest clear support for its partial adoption in the longer term: remote contacts are seen as valuable for staff meetings, and for convenient and environmentally friendly follow-up of well-engaged clients with access to and a positive view of technology. however, staff give a very clear warning that there are still important technological, social, and procedural barriers to be addressed, and that its use should remain selective, complementing rather than replacing face-to-face contact. this and other innovations that we document above suggest that, as in other domains of healthcare, there has been considerable agility and flexibility in at least some service contexts during the current crisis, with urgent needs overcoming well-documented barriers to implementing new ways of working. however, while responses to our question about innovations that staff would like to retain were numerous, serious concerns regarding both the short and long-term future were also widely expressed: these data were collected at a very early stage in the covid- pandemic. mental health services in the uk were already under pressure prior to the pandemic [ ] and swift attention, strategic planning, and resources will be required to meet widely anticipated additional demands from people affected directly or indirectly by the impact of the pandemic. this is only one perspective on the impact of the pandemic on mental health care, albeit one rooted in direct experience: it will be essential to investigate service user and carer perspectives, and to measure impacts on the mental health system more systematically as further data become available. given the unprecedented pace of change in the world and in mental health services, we prioritised gaining a broad overview of impacts and responses, but much detail will have been missed. our questionnaire was by necessity an ad hoc and not an established and validated tool. omissions were noted as the study progressed: it was assumed that impacts of the "lockdown" for service users were negative, but positive experiences are noted too, for example of reduced pressure or easier access for people who struggle to travel [ ] . more importantly, we designed the questionnaire early in the pandemic when the evidence of differential effects on some ethnic groups was less striking [ ] : closed questions do not focus on this, although these effects and issues of racism are included in open-ended responses on concerns for the future. our sample, gathered by disseminating our questionnaire through a range of channels, is not representative of those who work in mental health care settings, and may either over-represent people who have strong concerns about the situation or those who wish to report successful new practices. we managed to include a range of professions and work settings, but did not recruit as successfully as we had hoped outside the nhs-more targeted efforts and time are likely to be needed to reach relevant staff from other sectors. many people with mental health difficulties also come into contact with gps, pharmacists, paramedics, and a&e doctors and nurses, especially if they are not under secondary services; we have not included these perspectives. we are especially concerned that, while we do not have any definitive overall figure for the uk mental health care workforce, it is clear that the number of non-white participants in our survey is relatively small, despite targeted efforts to increase their number and a strong emphasis on anonymity and confidentiality, as advised in the previous discussions of this frequently experienced difficulty [ ] . further efforts to engage and form partnerships are likely to be needed here too. london also appears over-represented and rural areas, which may have distinctive challenges, under-represented, and we have not at this stage disaggregated data by country, region, or area type. we present here a series of snapshots capturing, from a staff perspective, the situation in mental health care services in the rapidly evolving early stages of the covid- pandemic. this work cannot yield definitive answers and should be interpreted alongside other perspectives, but offers researchers, service commissioners, managers, and policy makers directions for service development and further rapid research. regarding immediate priorities, our findings point to specific challenges to be addressed to achieve more successful infection control. remote working is a further immediate focus for research and service developments. participants' accounts suggest that it has been helpful in keeping services going and maintaining some level of contact in the community, and aids communication between staff. there is now a need to develop clearer processes in collaboration with service users for its targeted use, to implement guidance and evidence that already exists [ ] , and to explore ways of overcoming barriers to its effective use. mental health providers in the uk and elsewhere have demonstrated unprecedented capacity for rapid adaptation and innovation during the early pandemic period. recovery from the pandemic is a potential opportunity to establish new ways of working, for example with greater co-production with service users, and more widespread implementation of effective interventions and technologies [ ] . this will require sufficient resources, rapid production and translation of evidence, effective planning that engages all stakeholders, and great attention to workforce support and prevention of burnout. it is reassuring to see that staff share many of our concerns about the covid- pandemic: premature discharges, isolation, difficulties with infection control, and accessing care. many of these are reflected in the madcovid project's materials (https ://madco vid.com/). telemedicine drew mixed views from staff; we would like to highlight some difficulties. not everyone has a safe space to speak, may only have privacy in their bedroom or none at all. telemedicine works better for those in better, not-overcrowded housing, so risks widening inequalities in access to care. for many of us, our home is our safety, and it is important to have distressing conversations elsewhere. leaving the therapy room, we can leave some of our trauma behind. video calls may feel invasive-as though the clinician is in your bedroom-bringing up traumatic issues inside the home, where we cannot escape them. any continuation of remote working will need to consider the safety implications of this, assessing its suitability for each individual. it is vital that difficulty adhering to infection control guidance does not lead to blaming inpatients for viral spread. this is particularly important with restraint, where staff mentioned struggling to put on appropriate ppe in time to deal with an unfolding emergency. wide area variations in restraint rates (https ://www.mind.org.uk/media -a/ /physi cal_restr aint_final _web_versi on.pdf [ ] ; https ://weare agend a.org/ wp-conte nt/uploa ds/ / /restr aint-foi-resea rch-brief ing-final .pdf [ ] ), alongside personal experience, make us question whether restraint is ever truly unavoidable. if it places both staff and service users at risk of covid- infection, it is doubly dangerous. however challenging the situation, efforts must be renewed to reduce the iatrogenic distress, fear, and anger which can lead to its use. historically slow-moving services have implemented change at breakneck speeds in response to this crisis despite significant difficulties. service users have campaigned for changes for decades. it is time to implement these changes with the same urgency. the survey dataset is currently being used for additional research by the author research group and is, therefore, not currently available in a data repository. a copy of the survey is available at this web address: https ://opini o.ucl.ac.uk/s?s= . conflicts of interest sj, as, ble, so, and sc are grant holders for the nihr mental health policy research unit. ethics approval the king's college london research ethics committee approved this study (mra- / - ). consent to participate information on participation was provided on the front page of the survey. by starting the survey, participants agreed that they had read and understood all this information. it was explained on the front page of the survey that responses may be used in articles published in scientific journals and that these articles will not include any information which could be used to identify any participant. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/ . /. psychiatrists see alarming rise in patients needing urgent and emergency care and forecast a 'tsunami' of mental illness the lancet psychiatry. mental health and covid- : change the conversation ( ) mental health in the age of coronavirus: time for change. social psychiatry and psychiatric epidemiology the covid- global pandemic: implications for people with schizophrenia and related disorders quality of life, autonomy, satisfaction, and costs associated with mental health supported accommodation services in england; a national survey expert reaction to new advice to support mental health during the covid- outbreak physical health pandemic vs mental health 'epidemic': has our mental health been forgotten? mental health today mental health services in lombardy during covid- outbreak patients with mental health disorders in the covid- epidemic the covid- outbreak and psychiatric hospitals in china: managing challenges through mental health service reform remote consultations in the era of covid- pandemic: preliminary experience in a regional australian public acute mental health care setting innovation during covid- : improving addiction treatment access covid- mental health policy research unit group ( ) first reports regarding impacts of the covid- pandemic on mental health care and on people with mental health conditions: an international document analysis using mixed-methods sequential explanatory design: from theory to practice using the framework method for the analysis of qualitative data in multi-disciplinary health research three approaches to qualitative content analysis our concerns about mental health, learning disability and autism services funding and staffing of nhs mental health providers: still waiting for parity. the king's fund disparities in the risk and outcomes of covid- increasing response rates amongst black and minority ethnic and seldom heard groups video consultations: a guide for practice how mental health care should change as a consequence of the covid- pandemic physical restraint in crisis: a report on physical restraint in hospital settings in england briefing on the use of restraint against women and girls key: cord- -yjn sja authors: o'connor, daryl b.; aggleton, john p.; chakrabarti, bhismadev; cooper, cary l.; creswell, cathy; dunsmuir, sandra; fiske, susan t.; gathercole, susan; gough, brendan; ireland, jane l.; jones, marc v.; jowett, adam; kagan, carolyn; karanika‐murray, maria; kaye, linda k.; kumari, veena; lewandowsky, stephan; lightman, stafford; malpass, debra; meins, elizabeth; morgan, b. paul; morrison coulthard, lisa j.; reicher, stephen d.; schacter, daniel l.; sherman, susan m.; simms, victoria; williams, antony; wykes, til; armitage, christopher j. title: research priorities for the covid‐ pandemic and beyond: a call to action for psychological science date: - - journal: br j psychol doi: . /bjop. sha: doc_id: cord_uid: yjn sja the severe acute respiratory syndrome coronavirus‐ (sars‐cov‐ ) that has caused the coronavirus disease (covid‐ ) pandemic represents the greatest international biopsychosocial emergency the world has faced for a century, and psychological science has an integral role to offer in helping societies recover. the aim of this paper is to set out the shorter‐ and longer‐term priorities for research in psychological science that will (a) frame the breadth and scope of potential contributions from across the discipline; (b) enable researchers to focus their resources on gaps in knowledge; and (c) help funders and policymakers make informed decisions about future research priorities in order to best meet the needs of societies as they emerge from the acute phase of the pandemic. the research priorities were informed by an expert panel convened by the british psychological society that reflects the breadth of the discipline; a wider advisory panel with international input; and a survey of psychological scientists conducted early in may . the most pressing need is to research the negative biopsychosocial impacts of the covid‐ pandemic to facilitate immediate and longer‐term recovery, not only in relation to mental health, but also in relation to behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we call on psychological scientists to work collaboratively with other scientists and stakeholders, establish consortia, and develop innovative research methods while maintaining high‐quality, open, and rigorous research standards. the global impact of the coronavirus disease (covid- ) is unprecedented. by the june , in excess of million cases of covid- worldwide had been confirmed and covid- -related deaths were close to half a million. however, its impact should not only be measured in terms of biological outcomes, but also in terms of its economic, health, psychological, and social consequences. the covid- pandemic is unique with respect to the ongoing risks associated with the large numbers of infected people who remain asymptomatic, the impacts of the countermeasures on societies, the likelihood of second or third waves, and the attention it has received due to its global reach (particularly in high-income countries). the effects of the covid- pandemic will likely shape human behaviour in perpetuity. psychological science is uniquely placed to help mitigate the many shorter-and longer-term consequences of the pandemic and to help with recovery and adjustment to daily life. the immediate research response to covid- was rightly to focus resources on the transmission of covid- , identify biologics with which to treat those infected with the virus, and develop vaccines to protect populations. however, biomedical science can only go so far in mitigating the severe negative health, economic, psychological, and social impacts of covid- . the future availability of a vaccine currently remains uncertain; therefore, the primary weapons to mitigate the pandemic are behavioural, such as encouraging people to observe government instructions, self-isolation, quarantining, and physical distancing. even if a vaccine becomes available, we will still require changes in behaviour to ensure its effective delivery and universal uptake, so we need to prioritize research that will make the greatest contributions to our understanding of the effects of, and recovery from, the pandemic. the important contributions made by psychological scientists to understanding the impact of previous pandemics, including the ebola disease outbreak, severe acute respiratory syndrome (sars), and the middle east respiratory syndrome (mers), are welldocumented and mean we knew already a lot about public messaging and stress among frontline workers when the covid- outbreak began (e.g., brooks et al., , holmes et al., rubin, potts, & michie, ; tam, pang, lam, & chiu, ; thompson, garfin, holman, & silver, ; wu et al., ) . however, the unique features of covid- , including its virulence, the large proportions of people who remain asymptomatic but may still spread the virus (centre for evidence-based medicine, ), the stringent lockdown procedures imposed at pace on whole societies, and its global reach mean there is an urgent and ongoing need for social science research (world health organisation, ) . the collective and individual responses to severe acute respiratory syndrome coronavirus- (sars-cov- ) and to the introduction of measures to counter it have fundamentally changed how societies function, affecting how we work, educate, parent, socialize, shop, communicate, and travel. it has led to bereavements at scale, as well as frontline workers being exposed to alarming levels of stress (e.g., british medical association, ; greenberg, docherty, gnanapragasam, & wessely, ) . there have additionally been nationwide 'lockdowns' comprising physical distancing, quarantines, and isolation with the associated effects on loneliness, forced remote working, and homeschooling (e.g., hoffart, johnson, & ebrahimi, ; holmes et al., ; lee, ) . however, as well as having adverse psychological effects, the measures introduced to fight the pandemic may have led to positive social and behavioural changes. most obvious are the remarkable levels of compassion and support that have developed among neighbours and within communities as well as positive changes in behaviours such as hand hygiene, homeschooling, and physical activity. therefore, in addition to mitigating the negative effects of the pandemic, it is important to understand how any positive effects can be maintained as restrictions ease. there are, and will undoubtedly continue to be, inequalities in the effects of the pandemic and its aftermath; recognizing these vulnerability and resilience factors will be key to understanding how the current situation can inform and prepare us for dealing with future crises. of course, while we, as psychological scientists, are interested in the general effects of the pandemic, we are acutely aware of the fact that these effects disproportionately impact on different groups (box ). the issue of inequality is of central importance and runs through the research priorities that we describe below and it is a picture is emerging of covid- not as a single pandemic, but multiple parallel pandemics with some people facing numerous severe challenges and others experiencing few or none (williamson et al., ) . for those most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. a clear priority for psychological scientists is to understand how best to help those in need and to consider the following factors in their research efforts. in western europe and the united states, the death rate among people with black, asian, and minority ethnic backgrounds is substantially higher than that of the general population. it is not known what is causing the disproportionate impact nor how it can be mitigated. psychological science is in a good position to explore the biopsychosocial antecedents and consequences of having a black, asian, or minority ethnic background in the context of covid- . individuals living in poverty face disproportionate challenges in relation to education, work, income, housing, and physical and mental health. for these most vulnerable groups, the social, economic, and consequent psychological challenges of the pandemic are likely to be far-reaching and sustained. moreover, an impending financial crisis means that people who have never before experienced hardships may suddenly find themselves in precarious circumstances. a quarter of people in the uk experience mental health problems every year, with particularly high levels in young people (mental health foundation, ) . the changed social conditions of the pandemic may increase the severity of mental health challenges, particularly when standard (face-toface) treatment and support are difficult to access. at the same time, pregnant women and those with existing long-term conditions such as transplant patients, cancer patients, and chronic obstructive pulmonary disease patients have been designated 'extremely vulnerable' and asked to self-isolate for long periods of time with uncertainties over access to support. those individuals who have recovered from covid- might also have new biological vulnerabilities, uncertainty over immunity post-covid- , and risk stigma arising from infection. individuals with disabilities, learning disabilities, special educational needs, and developmental disorders may also be more vulnerable due to the increased psychological challenges associated with shielding and self-isolation. the challenges generated by the pandemic vary markedly across the lifespan and will influence the nature of current and future psychological needs of different groups. many young people have struggled with reductions in direct social contact, decreased motivation, and uncertainty caused by disrupted training and education. adults have experienced multiple stresses as a consequence of intensified caring responsibilities, financial concerns, job uncertainty, and health conditions. for many older people, the greatest challenges have been social isolation, disruptions in access to health and social care, and coping with bereavement. in addition to the challenges surrounding age, there are emerging data to suggest that the effects of covid- may exacerbate existing inequalities for women. for example, women are more likely to be key workers and primary caregivers, thereby being exposed to higher levels of psychological and financial stress (fawcett society, ). the covid- pandemic is likely to have had a disproportionate impact on groups with low levels of social inclusion and/or those who traditionally have declined support services, such as people living in poverty, traveller communities, and people who are homeless. being separated from wider support networks may also be particularly difficult for those living in hostile households such as victims of domestic abuse and lgbt people living with family members who are unaccepting of their identity. many of those detained in secure settings have been exposed to marked changes in service delivery and reduced social contact, increasing their vulnerability to the psychological effects of the pandemic. surely not a coincidence that the murder of george floyd during a global pandemic prompted a global civil rights movement drawing attention to inequalities. in this position paper, informed by a group of experts and a survey (box ), we highlight the many ways in which psychological science, its methods, approaches, and interventions can be harnessed to help governments, policymakers, national health services, education sectors, and economies recover from covid- (box ) and other future pandemics (if they occur). specifically, we have identified the shorter-and longerterm priorities around mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness in order to ( ) frame the breadth and scope of potential contributions from across the discipline, ( ) assist psychological scientists in focusing their resources on gaps in the literature, and ( ) help funders and policymakers make informed decisions about the shorter-and longer-term covid- research priorities to meet the needs of societies as they emerge from the acute phase of the crisis. the methodology we employed to develop the main research priority domains is described in box , and the seven priority domains are outlined below and summarized in table . how does collective identification impact on social responsibility and adherence to anti-pandemic measures? one of the most striking aspects of the covid- pandemic has been the importance of social psychology to the outcomes. given the highly differentiated nature of susceptibility to the virus (box ), one might have expected many (especially the young and fit) to conclude that they have more to lose than gain by observing the rigours of lockdown and other preventative measures. if they had acted on such an individualistic calculus, then far more people would get infected and far more (especially the old and infirm) would die. however, on the whole, people did not act on the basis of such narrow self-interest, and the vast majority supported the lockdown (e.g., duffy & allington, ) . what is more, conversely, well-functioning social support is likely to confer resilience against the negative psychological impacts of the pandemic. finally, it is important that psychological scientists consider the interconnectedness of the above factors. for example, individuals who are young and from a bame background who are also from a less affluent socio-economic background may be disproportionately impacted by the educational, economic, and other consequences of the measures taken to contain and recover from the pandemic. similarly, many of the solutions to the problems posed by the pandemic involve the use of new technologies that assume the requisite skills, access to devices, and internet connectivity meaning that the 'digital divide' will likely have been exacerbated by the pandemic (ons, ). this paper outlines research priorities for psychological science for the covid- pandemic. in april , the british psychological society convened a core group of nine experts who met regularly for weeks in order to develop the research priorities. the nine experts represent broad areas of the discipline, namely biological, clinical, cognitive, developmental, educational, health, occupational, and social, and were assisted by a wider advisory group of psychological scientists (n = ) drawn from a range of uk higher education institutions and areas of research expertise. we also received input from two international experts. briefly, we used an iterative expert consensus procedure (e.g., merry, cooper, soyannwo, wilson, & eichhorn, ) to elicit and distil the judgments of experts on the research priorities for psychological science. unlike other consensus methods, which typically start with a list of priorities that are then ranked over the course of or meetings (e.g., fitch, bernstein, aguilar, burnand, & lacalle, ; mcmillan, king, & tully, ) , the present approach both generated and judged the priorities over hour long face-to-face meetings of the core group. consensus was achieved through discussion, and the experts were encouraged to discuss with the wider advisory group and their professional networks in between meetings. given the need to establish the priorities rapidly, a lengthy consultation process or an extensive review of all relevant scientific literatures was not possible. however, a brief online survey of psychological scientists was launched early in may with the aim of ensuring that the core and advisory groups had not missed any key research priorities, and to identify the highest ranked priorities in each of the broad areas of psychology to help inform the final wider-ranging research priority domains. the online survey had two components: first, participants were asked the open-ended question, 'please can you tell us what are your priorities for psychological science research in response to the covid- pandemic?' second, participants were asked to rank order the top five research priorities identified by the core group in each of the eight broad areas of the discipline (i.e., biological, clinical, cognitive, developmental, educational, health, occupational, social). the survey was distributed to psychologists via heads of uk psychology department email lists, the social media outlets of professional psychology networks (including the british psychological society), and snowball email methods by the expert and advisory group members. we received replies from psychological scientists representing all of the main areas of the discipline. respondents were . % female, . % were aged between and years, and . % self-identified as being from a minority group. the highest ranked research priorities in each of the broad areas are presented in table (see appendix for the full list of priorities). as a result of the time constraints, a detailed qualitative analysis was not possible for inclusion in this paper; nevertheless, the core group gave consideration to all of the free responses provided. overall, there were differing degrees of specificity, and respondents provided numerous, additional, and wellspecified research questions. however, at the broadest level, respondents' priorities coalesced around the question of how do we address the negative biopsychosocial effects of the covid- pandemic? the degrees of specificity related to population (e.g., people with black, asian, and minority ethnic backgrounds, children, people with low socio-economic status, people living with long-term conditions), type of intervention (e.g., service provision, environmental/social planning), methodology (e.g., qualitative, online, survey, laboratory-based), and setting (e.g., workplace, school, prison), but there was broad agreement. perceived personal risk bears no relation to whether people adhere to government instructions: whether or not one identifies with the broader community and hence acts on the basis of the risks to the community as a whole is the key driver (jackson et al., ) . so, getting people to think in collective rather than personal terms is critical to controlling the pandemic (reicher & drury, ) . or, in the rather more forceful terms of new york governor andrew cuomo: 'yeah it's your life do whatever you want, but you are now responsible for my life. you have a responsibility to me. it's not just about you . . . we started saying, "it's not about me it's about we." get your head around the we concept. it's not all about you. it's about me too. it's about we'. how can we nurture the development and persistence of mutual aid and pro-social behaviour? the significance of such 'we-thinking' is not limited to issues of adherence and social responsibility. the literature on behaviour in disasters and emergencies (drury, ) suggests that the experience of common fate in such events leads to a sense of shared social identity that in turn underpins solidarity and cohesiveness between peopleeven strangers. we have seen numerous examples of 'we-thinking' in the time of pandemic, which have played a key role in sustaining people through difficult circumstances. these range from neighbours knocking on doors to see whether people need help to over three million people contributing to more than four thousand mutual aid groups across the uk (butler, ) . so, how can we nurture such we-thinking in order to build mutual aid in communities and ensure it endures even after the acute phase of the covid- pandemic is over? what is the relationship between group membership, connectedness, and well-being? there is growing evidence of the role of group membership in sustaining both physical and mental health (haslam, jetten, cruwys, dingle, & haslam, ) . in addition to asking in general terms about how group identities are created, sustained, or else undermined in times of crises, we also need to investigate further the interface between group processes and health during and after periods of crisis. in other words: how can we keep people psychologically together even when they are physically apart and what is the relationship between face-to-face and virtual groups in terms of their health effects? more generally, that is not to say that all research priorities were covered in the original survey. two issues in particular stood out from the comments we received. the first was the importance of dealing with inequalities and differences between groups in the experience of the pandemic. the second was the need to address the positive as well as the negative developments coming out of the response to covid- . these were both incorporated into revisions of the paper and now occupy a much more central place than before. we are thankful to all those anonymous respondents whose comments helped improve our argument. a more rigorous, thematic analysis of these data is now available (see bps, c). the picture was very similar when respondents were asked to place research priorities identified by the expert group into rank orders. that is, broadly speaking, the priorities that received the highest rankings, irrespective of area of subdiscipline, were related to the need to address the negative biopsychosocial effects of the covid- pandemic. box : psychological science: methods, approaches, and interventions to help meet the immediate and longer-term covid- research priorities the future research landscape will be challenging due to the ongoing physical distancing requirements; however, psychological scientists are equipped with a broad range of methods, approaches, and interventions that will allow these research priorities to be met. some examples are as follows: internet-mediated research will be an important approach utilized by psychological scientists to collect data in the immediate post-pandemic phase and at longer-term follow-ups. internet-mediated research can be reactive (e.g., online surveys, online interviews) and non-reactive (e.g., data mining, observations from screen-time apps) and can be integrated with objective assessments of behaviour as well as with biological and social markers of physical and mental health. internet-mediated research can also be used to run experiments with online software available such as gorilla, psychopy, and e-prime. recent work has summarized the range of software for building behavioural tasks, and their efficacy in being used online (sauter, draschkow, & mack, ) . changes in the use of research methodologies may provide a catalyst for the formation of new collaborations and training to develop research skills in the psychological science community. at the same time, trust around data security and confidentiality will need to be built between researchers and the general public from whom we sample. however, in , more than an estimated million people aged - years in the european union reported they had not used the internet in the preceding months (eurostat, ) , and researchers will need to think creatively about conducting research projects remotely. for example, participants can have study materials delivered by post (e.g., salivettes for cortisol sampling or asking participants to self-sample), replacing face-to-face communication with telephone and/or video calls, and the use of personal protective equipment when collecting data. psychological therapies and behaviour change interventions can already be delivered remotely and evidence suggests that remote delivery does not necessarily mean inferior delivery (e.g., irvine et al., ) . urgent research is needed to translate interventions that are typically delivered in-person to telephone and online delivery modalities. psychologists are well-positioned to collect valuable qualitative data concerning people's relevant experiences, perspectives, and practices associated with covid- , which could inform psychologybased interventions to improve well-being and social cohesion. multiple participant-centred qualitative research methods can be rapidly deployed to elicit first-hand accounts from members of different communities, including (online) interviews, focus groups, and qualitative questionnaires, focusing on the psychological and social impact (jowett, ) . beyond the immediate term, qualitative data can be gathered longitudinally so that insights can be generated into the experiences of diverse groups over time, identifying salient crisis points and effective resolutions. implementation science is a branch of psychological science that is dedicated to the uptake and use of research into clinical, educational, health care, organizational, and policy settings. principles of implementation science can be used to help stakeholders navigate the extensive and unwieldy psychological science research literature. to inform policymakers and support professional decisionmaking about implementation, psychological research needs to be disseminated in an accessible format. one example of a well-regarded translational system is the us institute of education sciences what works clearinghouse (https://ies.ed.gov/ncee/wwc/), which provides reviews and recommendations about evidence-based practices for professionals working in educational settings. can we learn from this in order to improve the plight of socially isolated people as we emerge from the acute phase of the pandemic? under what conditions does unity and social solidarity give way to intergroup division and social conflict? finally, in addressing the positive potential of social psychological processes, we must not forget their darker side. 'we' thinking can all too easily slip into 'we and they' thinking, where particular groups are excluded from the community and then blamedeven an important feature of the covid- pandemic has been requested by government to provide psychological science expertise at pace. the inclination of many psychological scientists is to begin designing a new study or conducting a systematic review following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, but this does not meet the needs of policymakers. it would be valuable for psychological scientists providing expert advice to acquaint themselves with the terminology and procedures that are familiar to civil servants who are more likely to have use for a quick scoping review or rapid evidence assessment (collins, coughlin, miller, & kirk, ) rather than embarking on a time-consuming systematic review of systematic reviews (keyworth, epton, goldthorpe, calam, & armitage, ) . there are many challenges involved with conducting covid- -related research including dealing with vulnerable groups, giving due consideration to ethical concerns, as well as issues around running studies in the light of physical distancing requirements. therefore, having relevant patient and public involvement and including individuals with lived experience (as appropriate) in designing studies will be of paramount importance. psychological science has been leading the way in promoting and adopting open science principles and practices. nevertheless, psychological scientists need to ensure they balance the urgency of conducting covid-related research (during and in the recovery period) with ensuring research quality and open research practices. therefore, in order to help maintain quality, openness, and rigour, we urge researchers to endeavour to use registered reports, where possible (e.g., https://osf.io/rr/), or preregister their research hypotheses and analysis plans (e.g., https://aspredicted.org/) and make their data findable, accessible, interoperable, reusable (fair) recognizing the principle of 'as open as possible; as closed as necessary' (bps, a (bps, , b norris & o'connor, ) . moreover, we urge researchers to utilize pre-print servers, such as psyarxiv, in order to ensure their latest research findings are made publicly available rapidly and at no cost. we hope that openness will drive quality, but as yet there is no substitute for articles being peer-reviewed prior to wider acceptance by the scientific community. psychological science has responded swiftly to the covid- pandemic, but there is a danger of duplication of efforts and participant fatigue in the proliferation of online surveys, experiments, and focus groups that have arisen. we need to harness the ongoing efforts of psychological scientists worldwide in a coordinated effort on the scale of the large hadron collider (cern, ) to deliver truly evidence-based interventions to help societies emerge from the covid- pandemic. this will include cross-cultural research to understand why mortality rates, mitigation measures, and adherence to government instructions have differed so markedly between countries. finally, we urge researchers to register their research studies and findings on international repositories (https://osf. io/collections/coronavirus/discover). attackedfor the crisis. thus, un head antonio guterres has warned of a 'tsunami of hate' unleashed by the pandemic (davidson, ) . this hate and violence can take different forms: of anti-authority riots as in france (willsher & harrap, ) , or of racist violence against minorities as in india (mazumdaru, ) . in sum, insights from social psychology can be a valuable resource in a crisis; it can bring people together and generate constructive social power. but equally, it can set people apart and create problems that endure well beyond the crisis itself. it is evidently of the greatest importance to understand the processes that determine whether people unite or divide in hard timesand notably to understand the role of leadership, which has been so significant and so diverse in different countries during covid- . work environment and working arrangements consistent with previous pandemics (e.g., rubin et al., ) , the work-related challenges of the pandemic have been particularly high and widely recognized for health and social what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? how will the covid- pandemic affect children's development? how will the covid- pandemic affect family functioning? how do school closures influence children's educational progress and well-being? what kinds of support improve long-term outcomes for children and young people? how can support services be effectively delivered to vulnerable children and young people, families, and schools? what are the immediate and longer-term consequences of covid- for mental health outcomes? what changes in approaches resulting from the pandemic need to be harnessed for the future? . physical health and the brain does covid- have neurological effects on the brain with consequences for mental health? what are the psychobiological impacts of the covid- pandemic on physical and mental health? how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? how do we develop new theories and tools to promote sustained behaviour change? care workers in direct contact with patients suffering the effects of covid- , leaving them vulnerable to trauma, fatigue, and other manifestations of chronic stress. what is unique about covid- is that changed working conditions and anxiety about infection have affected almost all employees, with particular challenges being faced by delivery workers, shop assistants, teachers, emergency services personnel, care home staff, transport staff, and social workers. the full economic severity of the covid-related restrictions is uncertain, although up to two million people could lose their employment in the uk alone (wilson, cockett, papoutsaki, & takala, ) . for those people still working, and those about to return to work, there are notable changes that will likely affect working practices in the foreseeable future. therefore, understanding the impact of the covid- pandemic on the work environment and new working arrangements is paramount to kick starting the economy and adjusting to daily life. what is the impact of remote and flexible working arrangements on employee health, mental wellbeing, teamwork, performance, organizational productivity, and colleague/client relationships? for many workers, particularly those in white-collar occupations, work took place entirely from home during the lockdown. it is possible that the lockdown will accelerate the general increase observed in home working practices (ons, ). a move to greater levels of remote working has clear economic benefits for employers (e.g., reduced estates costs). the flexibility to balance work and family life is also attractive to many employees (cf. strategic review of health inequalities in england, ). overall, the evidence points to positive benefits of remote working in terms of well-being (charalampous, grant, tramontano, & michailidis, ) , although these effects are not consistent. for example, it may lead to greater levels of professional isolation (golden, veiga, & dino, ). an increase in remote working will likely occur with a concomitant increase in the use of online technology to support communication and aspects of collaborative working. this has the potential to blur boundaries between work and home domains, resulting in negative impacts on well-being and productivity from work-home interference (van hoof, geurts, kompier, & taris, ) . greater use of technology may also be associated with different perceptual and cognitive demands that may affect productivity and wellbeing including social connections with work colleagues (e.g., mark et al., ) . what is the impact of physical distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? until an effective vaccine is available, physical distancing rules will need to continue to be in place in work environments and we may experience multiple stay-at-home versus return-towork cycles. there is very little research exploring physical distancing and its effect on the general workplace, but returning to work will likely be both a welcome change and a potential stressor. while we have research from teams working in difficult and extreme environments (power, ; smith, kinnafick, & saunders, ) and research on professional isolation (golden et al., ) , this is an unprecedented opportunity to study adaptation across a breadth of individuals and organizational settings. how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? the unprecedented demands that the pandemic has placed on organizations also offer a unique opportunity to understand how organizational resilience and preparedness for dealing with disruptions and emergencies can be developed. while a pandemic of this nature is rare, we can anticipate increasing periods of disruption due to covid- flareups and additionally, for example, in response to climate-induced events (e.g., recent australian fires, uk flooding), which are predicted to occur more frequently (banholzer, kossin, & donner, ) . although we know a lot about individual resilience, we know relatively little about organizational resilience, especially in the context of well-being and performance (taylor, dollard, clark, dormann, & bakker, ; fasey, sarkar, wagstaff & johnston, under review) and the ingredients such as the structures, processes, culture, and leadership that are essential for developing organizational resilience. parenting can be a challenging and anxiety-provoking experience at any time, but the covid- pandemic has brought these challenges and anxieties into sharp focus. for most families, the lockdown will represent the longest period of parenting they have experienced without ( ) the support of extended family members, friends, and childcare professionals; ( ) the routine of school and out-of-school activities; and ( ) any face-to-face social life outside the home. these changes in the social environment may have both negative and positive impacts on children and their families. at the most extreme end of the spectrum, the restrictions in place to combat the spread of the virus have been associated with worrying increases in domestic violence and child abuse. however, all families are likely to have experienced greater levels of stress (social care institute for excellence, ). the majority of carers with school-age children are dealing with homeschooling for the first time, and many carers are having to adapt to working from home while also looking after their children and older relatives. these pressures will be particularly acute for single-carer families. of course, such multi-tasking concerns apply only to carers fortunate enough to have maintained employment. it is important to support families during the current crisis, but also to understand the implications of these unprecedented changes in family life for family functioning and children's development as we emerge from the pandemic. how will the covid- pandemic affect family functioning? many effects of the pandemic on children's development are likely to be indirect, functioning through its impact on caregiving and family functioning. it is crucial for this research to include family members such as grandparents and non-resident parents and siblings. children in families who are already vulnerable due to domestic violence or abuse, social or economic disadvantage, or physical or mental ill health are likely to be most adversely affected. there is an urgent need for research to examine how these vulnerabilities moderate changes in family functioning post-pandemic and their impacts on the child. the ability to regulate behaviour and emotional responses is a key aspect of successful social interaction in individuals of all ages (e.g., baumeister & heatherton, ; kochanska, murray, & harlan, ) . family members may develop new self-regulation strategies as a result of having extended contact with the same restricted group of people. while such strategies may be adaptive, individuals facing extreme social or financial challenges may cope by psychologically distancing themselves from family members, ruminating on negative events, or engaging in behaviours that are harmful. understanding how adaptive and maladaptive self-regulation strategies change post-pandemic may prove useful in identifying individuals who need additional psychological support. school closures and social restrictions may provide a unique opportunity for family members to gain insight into each other's lives, potentially reducing disagreements and improving family functioning. research should investigate whether reporting such improvement during the crisis is associated with lower caregiving stress and better mental health. it is also important to study how families can maintain any positive aspects of functioning that have resulted from the pandemic as restrictions are eased. how will the covid- pandemic affect children's development? the effects of the pandemic will undoubtedly vary as a function of the child's age. while carers with young infants may have concerns about the negative impact of the lockdown on their babies' development, the infants themselves will be unaware of the abnormal nature of their social environment. optimal later development is predicted by caregivers' ability in the first year of life to see the world from the infant's point of view and respond appropriately to their cues (e.g., fraley, roisman, & haltigan, ; zeegers, colonnesi, stams, & meins, ) . the social restrictions do not obviously impede this type of infantcaregiver engagement, and young infants may therefore be least affected by the pandemic. older children who recognize the drastic changes in social contact may find transitioning back to pre-pandemic social behaviour difficult. it is therefore important to study how children and young people manage this transition and investigate whether the lockdown has raised the incidence of emotional and behavioural difficulties. studying the effects of the pandemic and its aftermath on particular groups that are known to be vulnerable to educational and health disadvantage (e.g., looked after children or children with developmental disorders) should be prioritized. positive effects of the pandemic on children's behaviour and social interaction are also anticipated. many children and young people will have found new ways to communicate with friends, entertain themselves, and keep themselves physically active. time away from school may have been spent learning new skills, developing new hobbies, or helping or supporting others. investigating changes in children and young people's empathy, altruism, theory of mind, creativity, innovation, problem-solving, and cognitive flexibility post-pandemic will help shed light on potential positive outcomes of the social restrictions associated with the pandemic. the challenges posed by the covid- pandemic have never been more evident than for the education and well-being of children and young people. in april , a third of the world's population were experiencing extended periods of lockdown with closure of schools and nurseries. parents, many of whom had work and other family responsibilities had to adopt the additional role of educator in home environments not set up for formalized learning. ad hoc arrangements were put in place at speed by schools with limited opportunities to develop clear definitions of learning activities, provide access to learning resources, and establish effective home-school communication. early surveys have shown wide variation in homeschooling arrangements, including stark differences between state and private schools in access to online learning and pupil-teacher communication (sutton trust, ) . there is a wealth of evidence about the factors that facilitate effective learning in schools, such as curricula and teaching strategies (hattie, ) . other studies have established that children's academic attainment and adjustment are predicted by higher caregiver education (erola, janolen, & lehti, ) and engagement in schooling (harris & goodall, ) . however, little is known on how to set up and deliver home education effectively under the unique conditions of the pandemic. while for some children the extended period at home is likely to have distinct positive benefits, research prior to covid- on substantial externally driven disruptions in schooling has shown adverse effects on child achievement and well-being (meyers & thomasson, ; sunderman & payne, ). the outcomes for the individual child are likely to depend on the capacity of families to step in and effectively support curriculum delivery at home. studies of other severe unplanned disruptions to schooling and family lives such as long-running strikes and natural disasters have shown greatest impacts on long-term educational and emotional outcomes for the most disadvantaged children (jaume & will en, ; masten & osofsky, ) . at particular risk of disproportionate adverse outcomes are children from families living in poverty, those receiving social care support, individuals with special educational needs and disabilities, and young people with mental health problems. there are high levels of concern that the recognized attainment gap for children from disadvantaged families (education in england: annual report . education policy institute) could be magnified by the pandemic conditions. there is an urgent need to identify and understand both the positive and negative factors that influence children's educational outcomes during and after the pandemic, and to use this knowledge to target support to those who need it most. the unanticipated consequences of the pandemic pose challenges for conventional designs depending on pre-intervention assessments. understanding its impacts on children's lives will require a robust body of research that draws on the diverse research methods of psychological science. this will require large-scale multidisciplinary data collection in addition to smaller-scale quantitative and qualitative approaches that will be vital for understanding the experiences of children, families, and professionals. some key questions to be addressed by this research are outlined below. in addition to collecting data on home-based support for learning, detailed contextual data are needed about social and environmental factors that are likely to interact in determining positive educational outcomes at particular educational phases (e.g., reading, writing, and maths in primary schools), as well as a range of mental health outcomes (e.g., anxiety, depression, self-harm, resilience). this will include research into the effect of social distancing on a range of social outcomes in children and young people (e.g., inclusion/ exclusion, friendships). what kinds of support improve long-term outcomes for children and young people? knowledge about the impacts of school disruptions on all children and young people will allow evidence-based interventions and resources to be targeted at those with greatest need. robust evaluations are required to scrutinize how interventions are accessed, by whom and with what degree of success. how can support services be effectively delivered to vulnerable children and young people, families, and schools? with reduced resources and restricted movement, professionals (such as practitioner psychologists) have had to adapt and develop new ways of delivering services. researchers in psychological science have a key role to play in working with practitioners and service providers to evaluate systems put in place for monitoring and delivering professional support during and in the aftermath of the pandemic. what are the immediate and longer-term consequences of covid- for mental health outcomes? there is expected to be an increase in mental health problems as a result of the covid- pandemic and the measures used to counter it. we already have evidence for the long-term mental health effects of previous pandemics and disasters (e.g., tam et al., ; thompson et al., ; wu et al., ) and an emerging literature on the near-term effects of covid- (e.g., ahmad & rathore, ; williamson et al., ) . but previous pandemics have been more localized and circumscribed making covid- different. social distancing, school closures, self-isolation, and quarantine have lasted longer than anything previously experienced. we know that these factors, together with financial uncertainty and concerns about health, are predictive of mental health difficulties, particularly anxiety. the current pandemic amplifies these factors and not only exacerbates problems in those with pre-existing mental health difficulties, but also increases the chance of new onset in those with no previous contact with mental health services. concerns about mental health effects may be particularly heightened for children, who have experienced high levels of disruption to normative developmental opportunities (including opportunities for social and outdoor play) and education, and potentially high levels of family stress (https://emergingminds.org.uk/cospace-study- ndupdate/). various poor mental health outcomes are also potentially associated with the disease itself. information about the long-term consequences comes from similar viruses such as sars and the mers. for example, many people who suffered from sars seemed to experience detrimental psychological effects even a year later (rogers et al., ; tam et al., ; thompson et al., ; wu et al., ) . therefore, we need to establish the immediate and long-term consequences of covid- on mental health outcomes in the population generally, but also in vulnerable, shielding, and self-isolating groups (box ). we urgently need to understand how all these factors interact and whether these consequences will require psychological interventions and supports not currently available. what changes in approaches resulting from the pandemic need to be harnessed for the future? even if the mental health consequences of this pandemic are not as predicted, we still expect increases in mental health problems. we know that mental health accounts for an increasing proportion of sick leave and that one in eight children and young people experience a diagnosable mental health problem (nhs digital, ) . childhood mental health problems often recur in adulthood (kessler et al., ) and are associated with physical health difficulties, poor academic, and occupational functioning, and are the primary predictor of low adult life satisfaction (layard, clark, cornaglia, powdthavee, & vernoit, ) . the increased prevalence will place a further burden on a mental health system that was already stretched and will increase waiting times and accentuate gaps in care. during the pandemic, mental health services rapidly changed. inpatients were discharged, even if they were detained in hospital because they were a risk to themselves or others. some people benefited, but we do not know how this reduction in bed use was managed. was it because the right supports and accommodation were provided? the move to remote contact in mental health services had been slow and of varied quality prior to covid- with challenges for both staff and service users. but the shift during the pandemic was swift, and although undoubtedly nhs staff felt pressure during the changeover, there now seems to be a steadier state. again, some service users may have benefited from this change with reductions in travel and, for some, better access to care and treatment. however, although the digital divide is reducing (robotham, satkunanathan, doughty, & wykes, ) , it remains highest in those who already have high unmet needs, including people in rural areas, those on lower incomes, people with lower levels of formal education, and older people. if remote working is tobe abeneficial part of an evolved mental health service, then we need to understand how to provide that 'webside' manner that will increase adherence and promote a therapeutic alliance. we also urgently need to evaluate the effectiveness of remotely delivered, digital interventions in the immediate and longer term. future interventions will need to be deliverable remotely, depending on local resources. for example, from an international perspective, many low-to-middle-income countries do not have high broadband penetration; hence, optimizing digital delivery that depends strongly on good internet connections will further widen the welfare gap. physical health and the brain the effects of covid- on health outcomes will be far-reaching and complex. for those falling ill, there are the direct consequences of the disease symptoms, such as respiratory failure in severe cases, alongside potentially direct viral effects on the brain. there are also more indirect population-wide effects of covid- pandemic-related stress and anxiety on physical and mental health, not only from the disease itself but also from changes in lifestyle including delayed treatment and screening for other known or suspected conditions. moreover, it is also likely that from an international perspective, in many lowto-middle-income countries, the pandemic will result in greater hunger/starvation, which will have severe impacts upon health. does covid- have neurological effects on the brain with consequences for mental health? at one level, covid- might alter mental health by the direct actions of the specific virus (severe acute respiratory syndrome coronavirus- ; sars-cov- ) on the brain. while neurological dysfunction is often described in covid- , including dizziness, and loss of taste and smell, these conditions are common to other respiratory tract infections and need not reflect a neurological disease per se (needham, chou, coles, & menon, ) . data from cerebrospinal fluid and post-mortem analyses will help resolve issues over the penetrance of sars-cov- . it is, however, known that the target receptor for sars-cov- is the angiotensin-converting enzyme- receptor (ace ). disruption of the blood-brain barrier during illness might enable entry of the virus, potentially aided by the presence of ace receptors in glial cells and brain endothelium. other potential routes of entry include the cribriform plate and olfactory epithelium, as well as via peripheral nerve terminals, permitting entry to the cns through synapse connected routes (ahmad & rathore, ) . at the same time, there is an array of immunological responses, including the cytokine 'storm' in severe cases, alongside non-immunological insults to the central nervous system provoked by covid- . the latter include hypoxia, hypotension, kidney failure, and thrombotic and homeostatic changes involving neuroendocrine function (needham et al., ) . together and separately, they may contribute to brain dysfunction in ways that vary with the severity of the infection, other underlying conditions (needham et al., ) , and the treatment for those other conditions (south, diz, & chappell, ) . largescale studies help confirm differential clinical risk factors for death following infection (williamson et al., ) , prompting genotype analyses, while noting that covid- might also induce epigenetic changes, including ace demethylation (sawalha, zhao, coit, & lu, ) . additional health concerns include post-viral fatigue and whether it might provoke a long-lasting syndrome. research consortia are initiating comparisons between populations that have or have not contracted covid- . challenges for psychological scientists include how to assess impacts on cognition and mental health, both in the short term and long term. a part of this challenge is how to deliver effective, online psychological testing (e.g., for 'shielded' populations), or to help follow-up large population cohorts, while not biasing the sample away from those least likely to use these platforms. an integral part of some investigations will be the inclusion of multiple neuroimaging methods, despite the era of distancing. just one of many questions would be the impact of covid- on mild cognitive impairment and its conversion to dementia. there is a premium on studying pre-existing cohorts (e.g., uk biobank, alspac), where retrospective, baseline data exist. such data are especially precious in the present landscape where everyone is, to some degree, affected by the pandemic. the power of these pre-existing cohorts will, however, be heavily influenced by the proportion of the population who contract covid- . what are the psychobiological impacts of the covid- pandemic on physical and mental health? despite the umbrella term 'stress' covering many different things, there is agreement that in its different forms, stress can lead to physiological changes (e.g., neuroendocrine, cardiovascular), with negative consequences for health (o'connor, thayer & vedhara, in press). three principal research questions can be identified: ( ) to what extent does pandemic-related stress, anxiety, and worry impact on biological mechanisms that influence health (i.e., hypothalamic-pituitary-adrenal axis regulation and cortisol dynamics, the autonomic nervous system, and gene expression) as well as on health behaviours (e.g., eating, sleep, alcohol consumption)? ( ) how best to counter their adverse effects? and ( ) how might such stress exacerbate existing medical and mental health conditions, and for how long? for all three questions, there will be considerable variations between groups and individuals (box ). one challenge will be to collate and verify relevant information, including that from 'smart' devices that can provide daily physiological data, activity information, and other measures of diurnal patterns, including sleep. one of the groups most likely to be negatively affected by stress is health care professionals. the pandemic may exacerbate the already high prevalence of secondary traumatic stress, burnout, and physical exhaustion among health care professionals, as well as impact on patient safety and medical error (e.g., dar & iqbal, ; figley, ; hall, johnson, watt, tsipa, & o'connor, ) , due to excessive workload and workplace trauma (e.g., itzhaki et al., ) . while resources such as support from managers and colleagues can help protect health care professionals against traumatic stress, the longerterm impact is likely to be substantial on individuals, their families, on the national health services and the wider care industry. amongst other groups of concern (box ) are those caring for a vulnerable relative or partner at home. one novel feature of daily life in the wake of the covid- pandemic in countries around the world are near-daily government briefings. one focus of these briefings is government instructions to the public as to how to behave. adherence to these and future instructions will be key to dealing with future crises. moreover, many sections above share in common the requirement that people adhere to instructions, whether it is practitioners delivering psychological therapies effectively over the telephone or employees continuing to maintain physical distancing at work. in the initial response to the pandemic, many governments instructed people to ( ) stay inside as much as possible; ( ) stay > m away from other people at all times; and ( ) maintain hand hygiene, among other measures such as wearing face coverings. the evidence suggests that public adherence to government covid- -related instructions worldwide has been high (ons, ), but it is not clear for how long people will continue to adhere to instructions that impinge on personal freedoms. what is clear is that there is a dearth of workers sufficiently trained to advise policymakers and to implement behaviour change interventions rapidly and at scale. the british psychological society's guidance on behaviour change is a good starting point for ensuring that instructions and messaging is clear (british psychological society, a). appointing chief behavioural science advisers to governments would ensure that cuttingedge psychological science advice is placed at the heart of policymaking. as people begin to emerge from the acute phase of the pandemic and the changes that were made to tackle it, it is important that psychological science is at the heart of ensuring that health-enhancing behaviours are sustained and that health-damaging behaviours are changed or prevented. there are numerous approaches to developing such interventions, including the behaviour change wheel (michie, atkins, & west, ) and intervention mapping (bartholomew eldrigde et al., ) , but they require the expertise of psychological scientists to deliver and to evaluate them (west, michie, rubin, & amlôt, ) . one of the main challenges now, and in the future, will be to ensure there is a workforce equipped with the competencies to develop behaviour change theory and tools that will bring about sustained changes in behaviour. taught post-graduate courses exist that could be scaled up and/or adapted to continuing professional development qualifications to meet this demand and help ensure that the changes in behaviour that will be required for the foreseeable future are sustained. how do we best apply existing theories and tools to promote sustained behaviour change among policymakers, key workers, and the public/patients? we sometimes forget that we have the theories and evidence for solutions that can be applied at pace to address novel problems. although we have never seen a lockdown before and so cannot predict what the outcomes will be directly, we do know what processes underpin adherence to instructions, and so can advise on the levers that can sustain adherence. in unprecedented and uncertain times now and in whatever the future might bring, the nature of psychological science allows us to make unique and invaluable contributions. if the covid- pandemic teaches us one thing, it is on the need to accelerate the translation of evidence from psychological science into practice. how do we develop new theories and tools to promote sustained behaviour change? at the same time, we should not forget the 'slow' approach to research (armitage, ) that involves addressing key research questions with multiple perspectives and methodologies, and accumulating such knowledge in prisma-guided systematic reviews. it is vital that continued investment is made into behaviour change research. only with this can we refine and develop the theories that best explain human behaviour (e.g., michie et al., ) . key research priorities include identifying which behaviour change techniques work best, for whom, in which contexts, and delivered by what means (e.g., epton, currie, & armitage, ) as well as how to counter the conspiracy theories and misinformation that arise during crises that seem to be aimed at derailing the very behaviours required to keep us safe and to reduce risk. in this position paper, we have set out seven research priority domains in which psychological science, its methods, approaches, and interventions can be harnessed in order to help governments, policymakers, national health services, education sectors, economies, individuals, and families recover from covid- . these are mental health, behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. we have also highlighted that a clear overarching research priority relates to understanding the inequalities in the effects of the pandemic and recovery; recognizing the vulnerability and resilience factors that will be key to understanding how the current pandemic can inform and prepare us for dealing with future crises. we call on psychological scientists to work collaboratively with other scientists in order to address the research questions outlined, refine them and to adopt multidisciplinary working practices that combine different disciplinary approaches. an important next step will be to engage with wider stakeholders, potential users, individuals with lived experience, and beneficiaries of the research. addressing each of the research priority domains will benefit enormously from larger scale working and coordinated data collection techniques and the establishment of research consortia with their associated economies of scale. we also call on psychological scientists to further develop and adapt innovative research methodologies (e.g., remote testing and intervention delivery, online data collection techniques), while maintaining high-quality, open, and rigorous research and ethical standards in order to help with the recovery as we emerge from the acute phase of the crisis. how can we use biological markers to facilitate people's return to work? how do we link covid- -related biomarkers to existing population cohort databases? how do we address the negative biological impacts of the covid- virus on mental health? what are the impacts of covid- infection, treatment, and recovery on the brain? how do school closures influence educational progress, and physical and mental health outcomes for all children and young people? what 'homeschooling' practices are associated with positive educational and psychological outcomes? what is the effect of social distancing on a range of social outcomes in children and young people? what methods are used to track, monitor, and deliver local authority support services to vulnerable children and young people, families, and schools during lockdown, at transition back to school, and after return to school? how are educational and psychological interventions allocated, structured, delivered, and evaluated for children and young people in need, after schools have reopened? what is the impact of remote and flexible working arrangements on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? what is the impact of social distancing in the workplace on employee health, mental well-being, teamwork, performance, organizational productivity, and colleague/client relationships? what managerial behaviours are most effective to manage remote working, possible mental health issues, job insecurity, and productivity? what is the risk of longer-term mental ill health among frontline staff after the immediate crisis? how can organizational resilience be developed to deal with the impact of covid- whilst supporting employees and protecting jobs? neurological manifestations and complications of covid- : a literature review changing behaviour, slow and fast: commentary on peters, de bruin and crutzen the impact of climate change on natural disasters planning health promotion programs: an intervention mapping approach self-regulation failure: an overview stress and burnout warning over covid- behavioural science and disease prevention taskforce. behavioural science and disease prevention: psychological guidance position statement on open data covid- research priorities for psychological science: a qualitative analysis the psychological impact of quarantine and how to reduce it: rapid review of the evidence covid- mutual aid: how to help vulnerable people near you. the guardian lhc the guide systematically reviewing remote e-workers' well-being at work: a multidimensional approach the production of quick scoping reviews and rapid evidence assessments: a how to guide beyond linear evidence: the curvilinear relationship between secondary traumatic stress and vicarious posttraumatic growth among healthcare professionals global report: virus has unleashed a 'tsunami of hate' across world, says un chief. the guardian the role of social identity processes in mass emergency behaviour: an integrative review the accepting, the suffering and the resisting: the different reactions to life under lockdown. the policy institute, king's college london unique effects of setting goals on behavior change: systematic review and meta-analysis parental education, class and income over early life course and children's achievement what do you use the internet for? defining and characterising organisational resilience in elite sport coronavirus: urgent call for uk government to support women and girls compassion fatigue: coping with secondary traumatic stress disorder in those who treat the traumatized the rand/ucla appropriateness method user's manual the legacy of early experiences in development: formalizing alternative models of how early experiences are carried forward over time the impact of professional isolation on teleworker job performance and turnover intentions: does time spent teleworking, interacting face-to-face, or having access to communication-enhancing technology matter managing mental health challenges faced by healthcare workers during covid- pandemic healthcare staff wellbeing, burnout, and patient safety: a systematic review do parents know they matter? engaging all parents in learning the new psychology of health: unlocking the social cure visible learning, a synthesis of over meta-analyses relating to achievement loneliness and social distancing during the covid- pandemic: risk factors and associations with 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effects of school closures during covid- email duration, batching and self-interruption: patterns of email use on productivity and stress disasters and their impact on child development: introduction to the special section coronavirus: eu fears a rise in hostile takeovers how to use the nominal group and delphi techniques mental health statistics: children and young people an iterative process of global quality improvement: the international standards for a safe practice of anesthesia paralyzed by panic: measuring the effect of school closures during the polio pandemic on educational attainment (no. w ) the behaviour change wheel: a guide to designing interventions neurological implications of covid- infections mental health of children and young people in england - science as behaviour: using a behaviour change approach to increase uptake of open science stress and health: a review of psychobiological processes exploring the uk's digital divide coronavirus and the social impacts on great britain extreme teams: toward a greater understanding of multiagency teamwork during major emergencies and disasters the two psychologies and coronavirus. the psychologist do we still have a digital divide in mental health? a five-year survey follow-up psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid- pandemic the impact of communications about swine flu (influenza a h n v) on public responses to the outbreak: results from national telephone surveys in the uk building, hosting and recruiting: a brief introduction to running behavioral experiments online epigenetic dysregulation of ace and interferonregulated genes might suggest increased covid- susceptibility and severity in lupus patients coping strategies used during an extreme antarctic expedition domestic violence and abuse: safeguarding during the covid- crisis covid- , ace , and the cardiovascular consequences strategic review of health inequalities in england post- does closing schools cause educational harm? a review of the research. information brief covid- impacts: school shutdown severe acute respiratory syndrome (sars) in hong kong in : stress and the psychological impact among frontline healthcare workers psychosocial safety climate as a factor in organisational resilience: implications for worker psychological health, resilience, and engagement distress, worry, and functioning following a global health crisis: a national study of americans' responses to ebola work-home interference: how does it manifest itself from day to day? applying principles of behaviour change to reduce sars-cov- transmission opensafely: factors associated with covid- death in million patients in a paris banlieue, coronavirus amplifies years of inequality. the guardian getting back to work: dealing with the labour market impacts of the covid- recession. institute for employment studies coronavirus disease (covid- ) the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perfection, and altruistic acceptance of risk mind matters: a three-level meta-analysis on parental mentalization and sensitivity as predictors of infant-parent attachment christopher armitage's contribution is supported by the nihr manchester biomedical research centre and the nihr greater manchester patient safety translational research centre. the views expressed in this publication are those of the authors and not necessarily those of nihr. armitage would like to thank professors madelynne arden and alison wearden for their support in writing. til wykes would like to acknowledge the support of her nihr senior investigator award. the set of priorities utilized for the survey of the psychological community.how do we increase adherence (and ability to adhere) to uk government covid- related instructions? how do we promote maintenance of positive behaviour changes and reverse negative behaviour changes resulting from covid- -related lockdown? how do we address the negative psychological impacts of the covid- pandemic? how do we maximize recovery from covid- for those infected with the virus? what is the impact of covid- -related stress on biological processes and health outcomes? what makes people adhere to anti-covid measures? what are the bases of anti-social behaviours such as stockpiling? how do mutual aid groups form and what makes them endure? when does social cohesion give way to scapegoating, prejudice, and intergroup conflict? what creates (or prevents) the potential for protests and collective disorder in the crisis? what are the long-term mental health effects of covid- ? what coping mechanisms are useful in reducing mental health problems during a pandemic? how do we provide beneficial remote psychological therapy and maintain therapeutic alliance? has discussion of mental health during the pandemic reduced stigma and discrimination in the community? people detained in hospital under the mental health act were discharged to free up bedshow was this possible? what are the impacts of covid- infection, treatment, and recovery on cognition, behaviour, and the brain? what are the drivers of covid- -related stress and its cognitive, neural, and physiological mechanisms and consequences? what are the perceptual and cognitive demands of digital and other alternative forms of communication and how do they impact on work and social connectivity? what factors influence the effectiveness of communication of scientific evidence and national guidance, and how do they influence behaviour? how do restrictions of movement, communication, and social support influence the cognitive, physical, and mental health of older individuals, and what factors lead to improved outcomes? how has the covid- pandemic affected parenting? how has the covid- pandemic affected children's development? how has the covid- pandemic affected family functioning? which factors moderate family members' response to the covid- pandemic? what support is most effective for families during the covid- pandemic? how do we assess biological markers of health and well-being remotely?continued key: cord- -fk s v authors: babatunde, gbotemi bukola; van rensburg, andré janse; bhana, arvin; petersen, inge title: stakeholders' perceptions of child and adolescent mental health services in a south african district: a qualitative study date: - - journal: int j ment health syst doi: . /s - - - sha: doc_id: cord_uid: fk s v background: in order to develop a district child and adolescent mental health (camh) plan, it is vital to engage with a range of stakeholders involved in providing camh services, given the complexities associated with delivering such services. hence this study sought to explore multisectoral dynamics in providing camh care in one resource-constrained south african district as a case study, towards informing the development of a model for district mental health plan and generating lessons for mental health systems strengthening to support camh services using the health systems dynamics (hsd) framework. hsd provides a suitable structure for analysing interactions between different elements within the health system and other sectors. methods: purposive sampling of key informants was conducted to obtain an in-depth understanding of various stakeholders' experiences and perceptions of the available camh services in the district. the participants include stakeholders from the departments of health (doh), basic education (dbe), community-based/non-governmental organizations and caregivers of children receiving camh care. the data was categorized according to the elements of the hsd framework. results: the hsd framework helped in identifying the components of the health systems that are necessary for camh service delivery. at a district level, the shortage of human resources, un-coordinated camh management system, lack of intersectoral collaboration and the low priority given to the camh system negatively impacts on the service providers' experiences of providing camh services. services users' experiences of access to available camh services was negatively impacted by financial restrictions, low mental health literacy and stigmatization. nevertheless, the study participants perceived the available camh specialists to be competent and dedicated to delivering quality services but will benefit from systems strengthening initiatives that can expand the workforce and equip non-specialists with the required skills, resources and adequate coordination. conclusions: the need to develop the capacity of all the involved stakeholders in relation to camh services was imperative in the district. the need to create a mental health outreach team and equip teachers and caregivers with skills required to promote mental wellbeing, promptly identify camh conditions, refer appropriately and adhere to a management regimen was emphasized. page of babatunde et al. int j ment health syst ( ) : policy documents have helped to spur this [ ] [ ] [ ] , notably the world health organization's (who) policy framework for child and adolescent mental health policies and plans [ ] . however, the paucity of specific national camh policies and national implementation guidelines, poor intersectoral collaboration and the shortage of camh resources still hinder the provision of optimal child and adolescent mental health services in many countries [ ] . the burden of camh has been well-described, especially in lmics [ , ] . barriers to camh service provision in lmics will undoubtedly be aggravated by the covid- pandemic, an event that will substantially test the resilience and responsiveness of district health systems. it has already been noted that the pandemic will add to the current camh burden, and a strong system of governance, service provision and financing will be vital to ensure the well-being of children and adolescents [ ] . two considerations have especially been part of strategies to reform camh services, namely task-sharing and intersectoral working. while camh services have historically been framed to be the sole responsibility of specialists, some recent studies have revealed the possibility and significance of integrating camh services into primary health care (phc) through the tasksharing approach [ , , , ] . notably, the mental health gap project (mhgap) [ ] includes guidelines for the management of several camh conditions at phc level within a task-sharing approach. in terms of intersectoral working, camh has historically been under the stewardship of the health sector. an intersectoral approach that involves the collaboration of other sectors such as education, social development and juvenile justice is required to achieve an effective camh system of care [ , ] . while these considerations have been central to south africa's health policy landscape, the country lacks a wellarticulated camh strategy which is required to achieve a functional camh collaborative system at a district level [ , ] . in the development of such a strategy, there is a need to involve a wide variety of stakeholders across multiple sectors, including caregivers, teachers, community and spiritual leaders [ ] . haine-schlagel et al. [ ] , emphasized that engaging various stakeholders was critical to achieving an effective camh service delivery. these multiple stakeholders, particularly teachers and caregivers (parents, grandparents, foster parents and other family members), are perceived to be active gatekeepers to camh care, given their vital role in identifying and seeking help for children and adolescents with mental (behavioural, emotional, social and developmental) disorders. despite the inclusion of camh in core national documents like the policy guidelines on child and adolescent mental health [ ] and the national mental health policy framework and strategic plan - [ ] , within the ideals of integrated, collaborative care (including task-sharing and intersectoral working, little to no guidance exists for provincial and district governments to translate national guidelines into operational tools for district governance of camh services. considering this, the study aimed to explore multisectoral dynamics in providing camh care in one resource-constrained south african district as a case study, towards informing the development of a model for district mental health plan and generating lessons for mental health systems strengthening to support camh services. the study was guided by the health service delivery (hsd) framework which describes health service delivery as a process by which policies, services providers and infrastructures are organized to achieve the goal of the health system which is to provide easily accessible and quality healthcare services [ ] . the framework consists of ten elements, they include, ( ) goals and outcomes, ( ) values and principles, ( ) service delivery, ( ) the population, ( ) the context, ( ) leadership and governance, ( ) finances, ( ) human resources, ( ) infrastructure and supplies, ( ) knowledge and information. the premise of the hsd framework is that the health system is an open system which is often shaped and influenced by different societal factors. it describes health service delivery as a process by which policies, services providers and infrastructures are organized to achieve the goal of the health system which is to provide easily accessible and quality healthcare services. moreover, resources such as budget allocation, human resources, infrastructure and supplies, knowledge and information are fundamental to achieving a viable healthcare system for the populace. the population (service users) are described as major players within the health system. the authors emphasized that they are not mere patients but also citizens having rights to access quality healthcare. governance, as described by the hsd framework, entails policy guidance, coordination of the different stakeholders and activities at different levels of care and effective distribution of resources to ensure equity and accountability [ ] . an instrumental case study which is used to obtain an in-depth understanding of specific issues was conducted with the amajuba district municipality as the unit of analysis [ ] to explore the experiences of providing and accessing camh services in the district. employing a phenomenological qualitative approach using semi-structured interviews, the design allowed for the generation of in-depth information about lived experiences from multiple stakeholder perspectives [ ] . the study was conducted in the amajuba district municipality, in the north-west region of the kwazulu-natal province of south africa. the district which covers km with a population estimate of about , , is made up of sub-districts and comprises rural and periurban communities [ , ] . amajuba has been identified as a resource-constrained district as it has limited numbers of health professionals, including mental health specialists to provide adequate health care services for the populace [ ] . the bulk of the district's camh service capacity is situated in its three provincial hospitals. the district was a site for government piloting of the national health insurance programme-a government-driven initiative aimed to unify south africa's two-tiered health system by establishing a centralised funding mechanism in order to achieve universal health coverage [ ] . as part of its pilot site status, the district had limited school mental health services as part of the integrated school health programme, an extension of the revitalisation of phc, that includes teams of health care workers (hcws) visiting schools to conduct basic screening and referral services [ , ] . research participants were purposively identified according to their positions in the departments of health, social development and education. snowball selection was applied, leading to the identification and participation of key role players involved in providing mental health care to children and adolescents in the district. participants included managers and mental health professionals from the department of health, managers, educators and mental health support workers from the department of basic education, non-governmental service representatives, as well as caregivers of children and adolescents living with mental health challenges. a list of camh cases and conditions identified in the district over months have been published elsewhere [ ] . these conditions included autism spectrum disorder, attention-deficit/ hyperactivity disorder (adhd), different forms of intellectual disability, depression, schizophrenia, bipolar affective disorders, mood disorder, anxiety, conduct disorder, mental and behavioral disorders tied to substance abuse. a full list of participants and the characteristics of children whose caregivers were included in this study are presented in tables and . data gathering for this study took place from february to march . semi-structured interviews were used, allowing for the use of probes and follow-up questions to steer the discussion while allowing for the generation of in-depth subjective information [ , ] . the interview guide was informed by the findings of an initial review of literature on the barrier and facilitators of camh services in low-and -middle-income countries [ ] and the hsd framework. the interview guide covered a range of questions that explored the roles played by each stakeholder in relation to camh services, their perceptions, and experiences of child and adolescent mental health; experiences of accessing and providing camh services, and suggested pathways for systems improvement. all the stakeholders included in this study were either physically visited in their offices or contacted via e-mail, text messages, and telephonically to inform them and solicit their participation in the study. the majority of the stakeholders responded positively, and interview dates and time were secured. the operational manager at the madadeni hospital psychiatric out-patient department and the clinical psychologist at the newcastle hospital assisted with identifying caregivers and introduced them to the researchers. the caregivers were then informed about the study during clinic days and twenty caregivers consented to participate in the study. interviews were conducted in english and isizulu, depending on interviewee preference. the primary researcher (gbb), a doctoral student, conducted the english interviews while the isizulu interviewers were conducted by a trained research assistant with a bachelor's degree, who is proficient with the use of both isizulu and english language. the research assistant is also a resident of the community, and this facilitated easy rapport with the stakeholders. the interviews were audio-recorded, transcribed verbatim, translated, and back-translated where required. transcribed data were analysed using gale et al. 's [ ] framework method, a summary process for managing and analysing qualitative data, which produces a series of themed matrices [ ] . accordingly, six steps were followed: ( ) transcription, ( ) familiarisation, ( ) deductive organisation of codes based on the elements of the hsd framework, ( ) inductive coding of sub-themes under the hsd coding framework, ( ) reviewing data extract and charting ( ) mapping and interpretation of data [ , ] . using these interconnected steps enabled the researchers to sort, scrutinise, categorise and chart the themes and associated sub-themes that emerged from the data set [ , ] . the categories were reviewed to identify existing connections and differences between the themes from the different groups of stakeholders [ ] . the excel software package ( ) was used in creating framework matrices and coding the entire data set. the accuracy of transcripts was checked against original recordings, and the two researchers (gbb and av) who conducted the analysis compared results at regular time points to harmonise the content of themes derived from raw data. also, the classification was discussed iteratively between the researchers, with input from study supervisors (ab and ip). to further ensure trustworthiness, the data set was thoroughly read through to confirm that the data was meaningfully clustered under the the themes and subthemes of the findings are presented here in narrative form, according to the constructs of the health system dynamics framework, starting with service delivery. direct quotations are added to illustrate key points. themes under this component will describe the structure of the camh system in the amajuba district. this includes a general "overview of camh services", and "identification and referral". camh services in amajuba district municipality were diverse. public sector professional mental health services were provided in a largely centralised fashion by psychologists based at the district regional hospital. this hospital served as a referral point for at-risk learners identified within the school system. service providers who helped to identify and refer children and adolescents potentially requiring mental health care were situated at different levels of the community, health and education systems, and included nurses in clinics, social workers in the communities, educators, learner support agents and school health nurses in schools. beyond the public health system, there were also a variety of non-government service providers who provided mental health services such as awareness campaigns, assessment and referrals to a limited degree. this included general practitioners, religious counsellors, non-governmental/non-profit organizations (ngos/npos) and traditional healers. in terms of the content of camh services, health care involved psychotherapy and psychopharmacological support, largely provided in the hospitals. educators and caregivers mentioned additional interventions to assist children in the school environment and at home. extra classes were organized for learners identified to be dealing with psychological challenges and struggling academically. they expressed that these interventions were insufficient and were negotiating for professional psychological assistance for the learners from the department of education. further, the department of social development provided disability grants to children with intellectual disabilities and autism, illustrated by the following: "i was advised to register her for the disability grant from the government, so that helps cater for her needs. we are fine financially because she receives the grant." (caregiver ). a service that was described as especially problematic was early identification of camh problems and appropriate referral; with most camh conditions identified and referred by the school system-but were generally quite late in the illness progression, when they were affecting children's academic performances. very few cases were identified by health workers in hospitals, phc clinics, ward-based primary health care outreach teams (wbphcots), or by the caregivers. this finding was illustrated by the following: "in most cases what i found is that children are identified by their educators. they are identified there in school and then referred to the clinic and then from the clinics to us here. and, there are few cases where children are brought to the hospital for other things and mental health issues are picked up as a secondary problem that is seen, but otherwise in most cases it's the educators unless a child has a clear mental health issue that is visible then the child is brought into the health system by the caregiver." (clinical psychologist ). once a child has been identified as needing mental health care, further steps depend on the specific space where identification occurred, and the nature of the perceived need. the educators and learning support agents (lsa) in schools mentioned that they provided some initial assessment and interventions before referring the children for further care. however, four of the twelve schools visited within the district still did not have any skilled staff or resources to provide initial camh assessment or interventions to assist their learners, they also did not have any information on the referral pathways. integrated school health programme (ishp) teams were yet to adopt mental healthcare into their activity portfolio. "we identify learners who have special needs, behavioral problems or learners who are abused physically, emotionally and socially. firstly, we screen those learners, fill the necessary forms and then we sit down with the learners to find out what the problem is, identify how we can help and if we cannot help, we call in supervisors from the dbe district office, then they will come and assist. they either do one-on-one sessions or sometimes they will take a group for assessment. after assessing them, if they see that the learners do have problems, they refer those learners to special schools. if it's a behavioral problem, they make sure that they do follow-up interventions like counselling or social work consultation and they refer some of the learners to the psychologists." (lsa, school c). a principal mentioned the need to train educators to prevent inappropriate referral and labelling. "….to take this matter seriously we need some resources to assist the schools, then the training of teachers also is important. i don't want teachers to wrongly identify and say it behaviour problem when the learner does not want to write due the relationships you have with that learner-so training of teachers is very important-so that they can be able to identify the learner." (principal ). a senior mental health professional highlighted that the psychologists are mostly the first point of contact for children and adolescents with camh conditions within the hospital (most of the referrals from the schools are addressed to them) and they refer them to the appropriate specialists for cases in need of more specialized interventions. according to one of the psychologists: "when they come to us, they are mostly accompanied by their caregivers, if maybe they come from school they come with their educators. so, we do the debriefing to sort of understand the child's condition and give us a picture of what is going on so that we can determine which services they need, and then if they need to be referred to other specialists, we do that. (clinical psychologist ) . the psychologist also mentioned inappropriate referral from schools, children with learning disabilities that should be referred to educational psychologists are referred to the clinical psychologists. this is due to the shortage of educational psychologists in the district, thereby resulting in back referral. "children with learning difficulties are often referred to us but we always refer them back to the department of education because they have an educational psychologist. we understand that she is the only one for the district, and she's not coping. because of this, schools tend to push them towards the department of health, but we don't do those assessments". (clinical psychologist ). the availability and organization of camh resources in the district are presented below, according to human resources, infrastructure, and supplies, knowledge, and information. participants described a severe shortage of human resources to deal with camh problems within the departments of health and basic education. the service providers within doh mentioned that they are overwhelmed due to limited camh human resources, increasing camh workload and inadequate camh training for non-specialists. there was a widely-held view that camh services are limited in the district, but there was also sympathy from several participants that the few service providers were doing their best, and-under the circumstancespurportedly provided highly responsive care. caregivers were appreciative of the good communication and friendly engagement of key mental health professionals. this was illustrated by the quotation below: "we got a very great help, they really helped us, especially the provincial hospital… the services were very good, and they were very helpful. the medication he receives here is helping a lot. they communicate with me properly, i was even able to ask questions and they could answer, they have been very caring towards me and the child, so i can say it was very good. " (caregiver ). the lack of mental health human resources, and the resulting limitations in providing care, was bemoaned by one mental health participant as follows: unfortunately, we can't see them more than once a month like everyone else because of staff shortage. however, if there is an urgent need for treatment, like sometimes we do fear that these persons might do something to harm themselves then we try to squeeze them in, but we just see them once a month. we usually make appointments in the mornings for people to come and see us… however, for school going-children we do make provisions for them, we see them in the afternoons, we schedule their appointments for pm, so that at least they will be able to go to school in the morning. " (psychologist ). some medical professionals noted that camh services provided opportunities for self-development, as most of them are medically qualified professionals without formal qualifications in psychiatry or child and adolescent psychology. "i enjoy providing camh services …it's very interesting and challenging but i learn from the experience and it motivates me to develop my skills…i was working with a doctor who was about to retire so i joined her and she exposed me to one or two things before she left. i have some years of experience in it now, but i'm not a child and adolescent specialist, we don't have any in the district as well. " (medical officer ). the psychiatrist suggested that the camh system could be strengthened through the development of outreach teams to expand the camh workforce, ensure consistent in-service training across all the departments involved in delivering camh services, particularly for phc nurses to facilitate the integration of camh services into primary health care, conduct awareness campaigns and provide psychosocial support to families to strengthen the existing camh system. schools so that they can do in-service training and awareness campaigns… visit families because they need to capacitate them and support them. also, training, i have been yearning for this, the phc staff members should undergo camh training. " (psychiatrist). findings revealed that there were very few special schools catering for children with special needs in the district, and only two of them were equipped to admit children with camh conditions. an educator from one of the two schools stated that the school was overpopulated due to the increasing prevalence of camh in the district: "at first, we had the capacity of , but due to the increasing number of children with mental disabilities we have about leaners, our school is full. " (educator , special school ). there was widespread concern about the challenge of finding suitable schools for children whose mental health needs could not be met by their current schools. some children were not enrolled into school at all, because they were rejected by the mainstream schools, with the limited special schools available in the district being overwhelmed due to the lack of space and shortage of resources. a caregiver relates this as follows: "i once struggled to find a school for him and i am still having that challenge because i am yet to find one that can accept him. " (caregiver ). in cases where caregivers were successful in placing their children in special schools, they received additional support in the form of transport services, as described below: "he is now studying in a special school, where they have trained teachers who are knowledgeable about his condition, so i am happy he is in the right place. they taught him how to write when he got there…he's now trying to write his name. it is just okay because they also provide him with transport. " (caregiver ). the chief director of special schools from the district department of education explained the school placement procedure. "first, we do the placement assessment, when a leaner is referred for special school placement. a committee which consist of an occupational therapist, physiotherapist, the hod and the class teacher will sit to decide. we assess the physical ability of the child and then cognitive assessment all these assessments will assist us with class placement. you know, sometimes the learner comes to us at the age of and never accessed any form of education, but we can't place them in the first year of school. after series of assessments, once we realize the level of assistance needed by the learner, we then recommend placement, we will then ask the parents to sign a consent form where they would agree that the learner should be enrolled into a special school. " (chief director, special schools). a caregiver also voiced her concern about the lack of higher education or opportunities for career development for adolescents with mental disabilities. "my worry is that when they reach the age of they should not just stay home, there must be something for them to do because people take advantage of children in these kinds of conditions because a lot of them tend to wonder in the street after they leave school. maybe the government could help build a school that can take those that are over the age of . " (caregiver ). there seemed to be a lack of knowledge in communities on identifying mental health symptoms at an early stage. in some cases, caregivers noticed some symptoms at an earlier stage, but they couldn't specify the nature of condition and did not access care for the child until they were identified and referred from school. these caregivers also mentioned that they could not seek help for the children because they didn't have a clear understanding of the conditions, where and how to seek medical care. this is illustrated below: "i noticed before the school called me, but i couldn't take any step because i didn't know what the problem was and where to take him for treatment until he was referred by the school, they gave me a letter and i took her to the hospital. " (caregiver ) . some caregivers reported that they noticed certain symptoms of abnormality. although they couldn't ascertain the nature of the problem, they immediately sought help for the child. two of the caregivers took their children to the clinics close to them and were referred to the hospital while others took their children directly to the hospital. however, the caregivers who took their children directly to the hospital mentioned that they were requested to obtain referral letters from the school or a clinic. the following excerpt refers: "we noticed the problem at home, but we couldn't identify it as autism, so i brought him here to the hospital but then they said i should get a letter from his school about his condition. " (caregiver ). the results under this component reveal the characteristics of the camh service users mainly caregivers of children with camh challenges in the district. government stakeholders described particular challenges in engaging with caregivers of children and adolescents with mental health needs. many caregivers were yet to accept their children's conditions and struggled to comply with the prescribed treatment regimen, and highlighted below: "i love working with the children but some of the caregiver are in denial they don't adhere to what you tell them whether its homework, time keeping, bookkeeping. it's kind of frustrating because you know the child should be improving, but the child is not because the parent or caregivers are not adhering. " (psychologist ). the challenging nature of child and adolescent mental health conditions led to many of the caregivers describing feelings of concern, helplessness and exhaustion, as expressed below: "i cried a lot and even now i haven't accepted it because i have two children, both have same condition. i accepted with the first one, but i couldn't accept with the second one. it was really hard, and people were talking all they want about me and making fun of me that they rejected my children from school. " (caregiver ). the complicated nature and under-resourcing of camh conditions further have a substantially negative effect on educators, not to mention the critical weight such conditions have on children's functioning, daily interactions with their environment, emotions, behaviors and academic performance, resulting in, among others, poor academic performance, school truancy and dropout. the below quotation refers: "their conditions affect us a lot; particularly it makes me sad. it affects us to such an extent that we end up not knowing what to do because we encounter such problems each and every day and there is no way we can help the children. it also affects their academic performance many of them are not doing very well academically, and some of them exhibit some behavioral problems. sometimes we spend extra time to assist some of them, we visit their homes and even give some learners money to buy grocery. " (educator ). participants pointed to the lack of a coordinated system of camh care as a major barrier to providing and accessing camh services in the district. this was exemplified by, particularly, poor intersectoral collaboration, and the lack of a standardised procedure and coordination for delivering camh services across the various departments in the district. there were no adequately integrated procedures for managing and reporting camh cases. one participant referred to the overall system of care for children living with camh conditions in the district as "disjointed". an example of this disjointedness was that certain services were packaged for children in different age groups across the two hospitals, which often required caretakers to find means of transporting the children between the hospitals to access different specialist services. this is illustrated in the quotation below: factors that were perceived to impede camh service provisioning from the wider contexts of the district emerged. the coalescence of the district disease burden and resource shortages resulted in very limited health awareness being conducted, which in turn resulted in poor mental health literacy. tied to this barrier, it was often mentioned that there are high levels of stigma towards mental illness among children and adolescents, illustrated by the following: "she does get discriminated which is something that pains me a lot. we are even afraid to send her to the shops and they even discriminate her because of the school she is going to. " (caregiver ). dysfunctional family systems were raised as a major risk factor and barrier to accessing camh services for children. the participants particularly emphasized the absence of parents-leaving children to the care of grandparents and other family members or leaving adolescents to care for themselves as a major problem in the community. the following quotation illustrates this point: "…most are from broken families; they stay with elderly people and we've got children heading the family. " (principal). "some of the parents are not staying with their children, they work and stay out of town… they come on month ends-just providing money-and leave the children to guide themselves. some children are in distressful situations because they were in a way abandoned by their parents. " (sanca coordinator). the study sought to explore service providers and service users' experiences of providing and accessing camh services and their perceptions of the available camh services in the district using the health system dynamics framework. key barriers and facilitators emerged for camh in the amajuba district municipality. certain community factors such as low mental health literacy resulting in misconceptions and stigmatization, and the dysfunctional nature of the family system within the communities were highlighted as major camh risk factors within the district that impedes access to camh services. community-based stigma can prevent caregivers from seeking help for their children, heflinger and hinshaw [ ] stated that stigmatization increases the burden caused by mental illness and is a major barrier to accessing and utilizing mental health services. according to brannan and heflinger [ ] , caregivers of children with mental disorders often experience the pernicious impacts of stigma and therefore delay accessing mental health services for their children. the study further revealed that the shortage of resources particularly camh specialists, lack of intersectoral collaboration and poor coordination, financial restrictions, and the low priority given to camh services in the district negatively impacts on the state of camh and serves as barriers to accessing camh services in the district. nevertheless, the few available camh specialists were perceived to be competent and dedicated to delivering quality services but could benefit from systems strengthening initiatives that could expand the workforce and equip them with the required skills, resources and adequate coordination. these findings corroborate the findings of a recent study conducted in the western cape province of south africa by mokitimi et al. [ ] which highlighted inadequate camh resources, lack of priority for camh services and low levels of advocacy for camh services as major weaknesses of camh services in the province. the shortage of educational psychologists which resulted in inappropriate referrals, disruption of assessment procedures for children with intellectual disabilities and increased workload for the limited available clinical psychologists was reported as a major barrier to camh services by the doh stakeholders. hence, the need to employ more educational psychologists by the department of education to address the needs of children with learning challenges was suggested. stakeholders also suggested the provision of in-service camh training for psychiatric nurses, school health nurses, social workers and phc workers which could facilitate the adoption of a task-sharing approach considering the shortage of camh specialists in the district. while schools play a vital role in the identification and referral of camh challenges [ ] , the dbe stakeholders reported that they lack the required skills, time and tools to adequately screen and refer children thereby hindering many children and adolescents living with camh conditions from accessing the required camh services. the lack of appropriately defined referral pathways for children and adolescents identified as having mental health problems also emerged as a major barrier to providing adequate camh services within the school environment. as mentioned earlier, the majority of children within the school environment identified as in need of mental health services were referred directly to the hospitals which resulted in bottlenecks, with long waiting lists. therefore, the dbe stakeholders suggested that efforts to build teachers' capacity to facilitate early identification, screening and referral for children and adolescents at risk to optimize their health and development, as well as their academic potential, should be explored. this would assist the teachers to distinguish between learning problems that should be referred to educational psychologists, social problems that require social work interventions and mental health conditions that require the services of clinical/counselling psychologists. a study conducted by cappella et al. [ ] , emphasized the significant roles of teachers in delivering camh services. they proposed the use of an ecological model to strengthen teachers' capacity and facilitate active collaboration with mental health specialist for the reformation of schoolbased mental health services in low resource settings. the study underlined the lack of a coordinated and integrated system of camh services particularly the lack of collaboration between the different sectors providing camh services in the district. this lack of adequate coordination and collaboration accounts for the inadequate communication between the different sectors, undefined screening/assessment procedure and referral pathways which results in delayed access to mental health care and the development of required interventions to address the various conditions affecting children. this finding is similar to the findings of previous studies conducted in ghana, uganda, zambia and south africa [ , , ] which identified the consequences of a weak intersectoral collaboration for the delivery of mental health services particularly camh services in low resource settings. the study participants emphasized the impact of camh conditions on the academic performance of children and adolescents which is further compounded by the shortage of special schools, the difficulties associated with securing school placements, the inadequate attention paid to the quality of education obtained and the lack of opportunities to pursue higher or vocational education after completing basic education for children and adolescents with camh challenges. many children and adolescents living with learning disabilities are not receiving the required educational help for their special needs leaving them to helpless. this finding corroborates the findings of a study conducted in a south african peri-urban township by saloojee et al. [ ] who found that many children with intellectual disabilities are not enrolled in schools. the caregivers mentioned financial constraints, lack of knowledge on how to access the available services and lack of psychosocial support which they encountered daily in their pursuit to alleviate the conditions of their children. previous studies [ , , , , , ] have also highlighted the psychological, physical and financial burden associated with caring for people with mental health challenges and the need to develop interventions that would equip caregivers with skills to alleviate these burdens. caregivers are central to camh prevention and effective management but require consistent support to acquire the necessary coping, communication, resilience, problem-solving and stress management skills. moreover, the need for intensive camh awareness programs was suggested by the participants as well as the need to organize camh outreach teams to disseminate camh information and implement community based camh services in the district. according to the participants, these strategies will increase the knowledge of camh within the communities and could eliminate stigma and misconceptions around camh conditions. however, hinshaw [ ] proposed that stigma operates on multiple levels and mere public education programs might not resolve the problem of stigmatization. therefore, the need to incorporates different change strategies targeted at the different interacting levels within the communities is required. while a purposive sampling technique was used in selecting the study participants to obtain in-depth information on the current state of camh in the district, we acknowledge the various categories of stakeholders were a product of the differential availability of the stakeholders. it is possible that we might not have adequately captured the perspective of other key informants, particularly those within other sectors outside the dbe, doh and ngos/ cbos partnering with doh and dsd. however, the study included different categories of stakeholders to obtain rich data about the experiences and perceptions of camh service delivery in the district. the findings of this study suggest the need to create a district camh intersectoral coordinating or liaison forum to facilitate joint camh service planning and implementation to develop intersectoral agreements, developing defined referral pathways between relevant sectors, mobilizing resources, optimizing available resources within each sector, clarifying roles and responsibilities of the different sectors, promoting awareness and staff training on camh. moreover, the need for continuous in-service training and capacity building through supervision and mentorship for stakeholders in each of the sectors cannot be overemphasized as in-service training, mentorship and specialists support can facilitate the acquisition and the willingness to implement new skills. additionally, the development of management guidelines specifying the management procedures (identification, assessment, referral, treatment/interventions) for each sector and at the different levels of care should be prioritized. it is important to address the educational needs of children and adolescents living with camh challenges by mobilizing resources such as providing learning equipment, building more classrooms and creating professional support teams to expand the capacity of the available special schools to accommodate children and adolescents living with severe camh conditions specifically learning difficulties in the district. increased attention should also be paid to educating and providing the necessary socioeconomic support for caregivers of children and adolescent with camh conditions. caregivers should be sensitized about the importance of actively participating and complying with the management regimen recommended for their children's conditions within the health care system and school. it is also important to invest in a rigorous approach to disseminating mental health education especially camh information within the district to eliminate discrimination and stigma. these information dissemination strategies should include the transmission of camh messages using public-social media platforms, ensure regular camh information contacts at the community levels and provide adequate support and education at the family level. in conclusion, the need to build the capacity of all the involved stakeholders in relation to camh services is imperative in the district. although teachers and caregivers are not in a position to treat camh conditions, they can be equipped to identify children and adolescents with incipient mental health problems so that they access care early on in the illness progressions. they can also be equipped with knowledge and skills to support children and adolescents with mental health problems and adhere to management regimens. teachers could be assisted to promote mental health and resilience, identify and refer camh conditions through enhancing their mental health literacy and providing them with validated and appropriate screening tools. creating mental health outreach teams could further facilitate camh awareness within the communities thereby enhancing camh literacy and access to quality camh services. this could also potentially relieve the burden of care placed on the limited specialists and ensure a functional and sustainable collaborative system of camh care in the district. amajuba district municipality spatial development framework. 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up care for mental, neurological and substance use disorders publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank all the study participants who devoted their time and insight, mr. mercury nzuza, miss. patricia ndlovu, mr. fortune ngubeni and miss. kgothalang rethabile khadikane for the support provided during the data collection phase. the views expressed do not necessarily reflect the uk government's official policies. the funder did not have any involvement in the study design, collection, analysis or interpretation of data or writing of the manuscript. gbb and ip conceptualised the study, gbb collected data, gbb and av analysed data and gbb drafted the manuscript. av, ab and ip reviewed the manuscript, provided substantive revision. all authors read and approved the final manuscript. this study is an output of the programme for improving mental health care (prime). this work was financially supported by the uk department for international development ( ). g. b. b receives the university of kwazulu-natal scholarship. the datasets used and analysed during the current study are available from the corresponding author on reasonable request. gatekeeper permission was obtained from the relevant government departments, and ethics approval was provided by the biomedical research ethics committee, faculty of health sciences, university of kwazulu-natal (reference number be / ). following an informed consent procedure, permission to participate and audiotape the qualitative interviews was obtained from each respondent. not applicable. the authors declare that they have no competing interests. key: cord- -tbv yja authors: arslan, gökmen; yıldırım, murat; karataş, zeynep; kabasakal, zekavet; kılınç, mustafa title: meaningful living to promote complete mental health among university students in the context of the covid- pandemic date: - - journal: int j ment health addict doi: . /s - - - sha: doc_id: cord_uid: tbv yja maintaining positive mental health can be challenging during the covid- pandemic which undoubtedly caused devastating consequences on people’s lives. there is need to determine factors contributing to mental health of people during the pandemic. the current study aims to examine the effect of meaning in life on complete mental health, which represents the presence of positive functioning and the absence of psychopathological symptoms. the participants of the study included ( . % female) undergraduate students, ranging in age from to years (m = . years, sd = . ) and they have predominantly been imposed stay-at-home orders for coronavirus right after announcement of covid- restrictions in turkey. latent variable path analyses demonstrated significant paths from meaning in life to all components of psychological distress, positive mental health, and subjective well-being. multi-group analysis showed significant gender differences across the study variables. these findings corroborate the critical role of meaning in life in promoting complete mental health and shed further light on why people high in meaning in life tend to have better mental health than those low in meaning in life within the context of covid- . ; spiker and hammer ; tanhan ) . mental well-being, on the other hand, includes the presence of fulfillment with emotional, social, and psychological experiences (keyes ; seligman and csikszentmihalyi ; smith et al. ) . the absence of mental illness does not completely reflect the presence of well-being or vice versa (keyes ). researchers suggested the continuity of mental health to describe one's fully functioning in social, emotional, and psychological domains (diener et al. ; keyes ) . a complete mental health can be achieved by considering both positive and negative states of mind and body. thus, as there are differentiated conceptualization of well-being, researchers have suggested to simultaneously measure different types of well-being (e.g., subjective and psychological well-being) and mental illnesses (e.g., depression and anxiety) to comprehensively understand mental health (ryan and deci ) . complete mental health is linked to coping, self-esteem, optimism, psychological flexibility, feeling of control, resilience, functioning, and adjustment (arslan ; arslan and allen ; bieda et al. ; keyes ; keyes ; moore and diener ; peterson and seligman ) . well-being typically refers to "optimal psychological functioning and experience" and is a multidimensional construct including hedonic and eudaimonic dimensions (ryan and deci ) . hedonic well-being typically reflects subjective well-being (swb) that incorporates satisfaction with life, positive affect, and negative affect while eudaimonic well-being is conceptualized as positive skills that promote living a life of virtue in pursuit of human excellence. eudaimonic well-being is best represented with psychological well-being (pwb) that includes six dimensions of optimal functioning: purpose in life, environmental mastery, autonomy, personal growth, positive relations, and self-acceptance (ryff and keyes ; ryff et al. ) . although swb and pwb are conceptually overlap to some extent, they are empirically distinct concepts (ryan and deci ) . research has shown that both swb and pwb are associated with psychosocial and physical outcomes. for example, in a systematic review study, lyubomirsky et al. ( ) documented that there are various tangible benefits of well-being such as better general health, effective coping strategies, fulfilling social relationships, and success. more recently, similar findings have been reported concerning the link between well-being and health outcomes (gruber and bekoff ; huang and humphreys ; kansky and diener ) , and self-productivity, success, subjective vitality, meaning, self-esteem, and marital satisfaction (akdağ and cihangir-çankaya ; braaten et al. ) . given that the perception of meaning in life and mental health of individual may be adversely affected during difficult times like the covid- pandemic, it is necessary to understand the link between meaning in life and complete mental health in such times. therefore, the main purpose of this study is to examine the association between meaning in life, psychological health problems, positive mental health, and subjective well-being. we hypothesized that meaning in life would be a significant predictor of all indicators of complete mental health and the predictive effect of meaning in life on indicators of complete mental health would differ across female and male participants. the participants included ( . % female and . % male) undergraduate students attending a public university in an urban city of turkey. they ranged in age from to years (m = . years, sd = . ). the unique characteristic of the participants is that % of them were under years old who have been imposed stay-at-home orders for coronavirus right after announcement of covid- restrictions. most of them considered themselves at medium-risk for coronavirus (low = . %; medium = . %; high = . %). all participants were informed about the aims of study and their rights to withdraw at any time from the online survey. a convenience sampling method was used to collect data. participants were not paid for their involvement. meaning in life meaningful living measure (mlm) was used to assess the meaning in life with a -item self-report measure that is scored based on a -point likert-type scale from strongly disagree ( ) to strongly agree ( ) (e.g., "as a whole, i find my life meaningful"). previous research has revealed that the mlm provided good data-model fit and strong internal reliability estimates with turkish adults (arslan b) . the scale had also a strong internal reliability estimate with the current sample (α = . ). psychological distress brief symptom inventory (bsi- ) was used to measure mental health difficulties of individuals (derogatis and fitzpatrick ) . the scale is an -item self-report questionnaire and includes three -item subscales: depression, anxiety, and somatization (e.g., "pains in heart or chest," "feeling no interest in things"). all items are responded using a -point likert-type scale, ranging from not at all ( ) to very much ( ). although psychometrics of the previous versions (scl- and bsi- ) of the scale have been examined with turkish samples, psychometric properties of current version are still not available. therefore, the psychometric adequacy of the bsi- was investigated using the sample of this study. confirmatory factor analysis results, which structured the observed bsi items as indicators of three subscales, indicated that the measurement model yielded adequate datamodel fit statistics (χ = . , df = , p < . , tli = . , cfi = . , rmsea [ % ci] = . ). factor loadings of the scale were strong ranging from . to . (somatization λ range = . -. ; depression λ range = . -. ; anxiety λ range = . -. ; covariance = - items and - items), and internal reliability coefficients (overall bsi- α = . ; somatization α = . ; depression α = . ; anxiety α = . ). these results provided good evidence for a three-factor model of the bsi- that could be used to measure psychological distress among young adults. positive mental health mental health continuum short form (mhc-sf) is a -item selfreport measure developed to assess individuals' social, emotional, and psychological wellbeing representing the level of positive mental health (e.g. "in the past month, how often did you feel that our society is becoming a better place for people?"; keyes et al. ). all items are scored using a -point likert scale, ranging between never ( ) and almost ( ). previous research has provided evidence supporting good psychometric properties in different cultures (keyes et al. ; petrillo et al. ) including turkish culture (demirci and ahmet ) . the scales had also strong internal reliability estimate with the present sample (α range = . -. , see table ). subjective well-being the scale of positive and negative experience (spane) (diener et al. ) and the satisfaction with life scale (swls) (diener et al. ) were combined to measure individuals' subjective well-being. the spane is a -item self-report questionnaire used to assess individuals' emotions and moods and includes two -item subscales: positive feeling experience (e.g., "pleasant," "good") and negative feeling experience (e.g., "unpleasant," "negative"). all items are rated on a -point likert scale, ranging from very rarely or never ( ) to very often or always ( ). research indicated that the scale had good psychometric properties and strong internal reliability estimates for turkish samples (telef ) . the swls was also used to assess individuals' cognitive assessments of well-being. the scale is a -item self-report instrument (e.g., "the conditions of my life are excellent") that is answered using a -point likert-type scale, ranging from strongly agree ( ) to strongly disagree ( ). previous research showed that the reliability coefficients of the swls were adequate for turkish sample (dağlı and baysal ) . the internal reliability estimate of the scale was strong in the present study (α range = . -. , see table ). prior to examining the predictive power of the meaning in life on complete mental health indicators, descriptive statistics and the assumption of normal distribution were investigated. following excluding the messing scores ( participants), skewness and kurtosis scores were used to investigate the normality assumption, and the estimates ≤ | | were considered as adequate for normality (d'agostino et al. ; kline ) . then, pearson's correlation analysis was conducted to examine the association between the study variables. subsequently, a pair of latent variable path analysis (lvpa) was conducted to examine the predictive effect of the mlm on student's complete mental health identified by positive mental health, psychological distress, and subjective well-being indicators. findings from path analyses were interpreted using the standardized regression estimates (β values) and squared-multiple correlations (r ), with traditional decision rules: . -. = small, . -. = moderate, ≥ . = large (cohen ) . findings from this analysis were also evaluated using several data-model fit statistics and their cut-scores: comparative fit index (cfi) and tucker lewis index (tli) values ≥ . were considered an adequate data-model fit; the root mean square error of approximation (rmsea; with % ci) values between . and . were viewed as a good data-model fit (hooper et al. ; hu and bentler ) . furthermore, multi-group analysis was conducted to investigate gender differences on the study variables. all statistical analyses were performed using spss version and amos version . findings from descriptive analysis showed that skewness and kurtosis scores ranged between − . and . , suggesting that all variables provided relatively normal distribution (d'agostino et al. ; kline ) . internal reliability estimates of the study variables were adequate-to-strong, ranging from . to . , as shown in table . further, correlation analysis was performed to investigate the association between variables, indicating that meaning in life was positively and significantly correlated with life satisfaction (r = . , p < . ), positive feelings (r = . , p < . ), and emotional (r = . , p < . ), social (r = . , p < . ), and psychological well-being (r = . , p < . ), ranging from moderate to large effect sizes. meaning in life had also significant and negative correlations with negative feelings (r = − . , p < . ), somatization (r = − . , p < . ), depression (r = − . , p < . ), and anxiety (r = − . , p < . ), ranging from small to large effect sizes, as shown in table . following conducting the descriptive and correlation analyses, the lvpa was performed to investigate the predictive effect of the measurement model on student mental health and wellbeing. overall, results of this analysis provided good data-model fit statistics (χ = . , df = , p < . , rmsea = . [ % ci . -. ], cfi = , and tli = . ). standardized regression estimates indicated that meaning in life significantly and moderately-to-largely predicted subjective well-being components, ranging from . to effect sizes: life satisfaction (β = . , t = . , p < . ), positive feeling (β = . , t = . , p < . ), and negative feelings (β = − . , t = − . , p < . ). subsequently, meaning in life had significant and strong predictive effects on positive mental health indicators, ranging from . to effect sizes: emotional (β = . , t = . , p < . ), social (β = , t = . , p < . ), and psychological well-being (β = , t = . , p < . ). lastly, findings of the study indicated the significant and large predictive effects of meaning in life on student psychological difficulties, ranging from . to effect sizes: somatization (β = − . , t = − . , p < . ), depression (β = − . , t = − . , p < . ), and anxiety (β = − . , t = − . , p < . ), see table and fig. . multi-group analysis was also performed to investigate the differences between male and female students. findings from the analysis showed that the model yielded good data-model fit statistics (χ = . , df = , p < . , rmsea = . [ % ci . -. ], cfi = , and tli = . ). standardized regression estimates showed that meaning in life had a strong predictive effect on psychological distress and positive mental health components in male students, compared with female students, as shown in table . this evidence suggests that the predictive effect of meaning in life differs across female and male students; thus, caution may be warranted in comparing these groups. the covid- epidemic becomes the most challenging global health crisis in the twenty-first century. although countries take necessary measures such as quarantine and self-isolation to decelerate, covid- is much more than a health crisis. it has the potential to create devastating psychological, social, economic, and political crises that will leave deep wounds as it has been continuing to affect many societies unprecedentedly. this can be a severe source of stress and anxiety for everyone. therefore, it is crucial for the individual to cope with stressors, adjust to the changes in general lifestyle due to covid- , and maintain their mental health. (rosenberg ) . meaning in life is one of the most important components of coping with stressors in difficult times. it is very important to develop an existential source of flexibility such as sense of meaning and purpose in this difficult process (kim et al. ) . the present study sought to examine the role of meaning in life in enhancing the mental health and well-being of undergraduate students during the covid- outbreak. we hypothesized that meaning in life would be a significant predictor of all indicators of complete mental health. the study results revealed that meaning in life negatively and significantly predicted negative effect and positively and significantly predicted positive affect and life satisfaction. similar to the findings of the present study, previous studies revealed that meaning in life was positively associated with positive affectivity and life satisfaction while negatively related to negative affectivity, which are essential components of subjective well-being (doğan et al. ; galang et al. ; santos et al. ; yıldırım and güler b) . arslan and allen ( ) reported that meaning in life was a significant predictor of life satisfaction and mediated the negative effect of coronavirus stress on well-being. santos et al. ( ) found that meaning in life was positively related to positive emotion and life satisfaction and negatively associated with negative emotions. cohen and cairns ( ) found a negative and significant correlation between searching for meaning in life and subjective well-being and a positive and significant correlation between the presence of meaning in life and subjective well-being. findings of the study additionally showed that meaning in life positively and significantly predicted positive mental health including emotional well-being, social well-being, and psychological well-being. this study has supported previous findings indicating that individuals with high level of the sense of meaning in life have grater emotional, psychological, and social well-being (damasio et al. ; garcía-alandete ; garcía-alandete et al. ; mulders ) . meaning in life significantly predicted psychological well-being (garcía-alandete ; garcía-alandete et al. ) . despite the literature supporting the importance of meaning in life to improve positive mental health, specifically psychological well-being, few studies have focused on the predictive effect of meaning in life on emotional and social well-being (garrosa-hernández et al. ) . therefore, the present study provides further evidence indicating that meaning in life is an important factor to promote not only psychological well-being but also emotional and social well-being. lastly, the results indicated that meaning in life had a negative and significant predictive effect on psychological health problems (i.e., depression, anxiety, and somatization), which are negative indicators of complete mental health. consistent with these results, the literature has indicated that the sense of meaningful living is the key to better psychological health (kleftaras and psarra ; mascaro and rosen , ; steger et al. ). for example, hedayati and khazaei ( ) found a negative correlation between meaning in life and depressive symptoms. another study indicated that there was a significant and negative correlation between meaning in life and anxiety, somatic symptoms, social dysfunction, and depressive symptoms. individuals with depressive symptoms reported lower levels of meaning in life compared with those without (kleftaras and psarra ). the current study focused on meaning in life, subjective well-being, and some indicators of positive mental health (emotional well-being, social well-being, and psychological well-being) and of negative mental health (depression, anxiety, and somatization). future research may investigate the relationships of meaning in life with different variables. as negative correlations were found between meaning in life and depression, anxiety, and somatization in the current study, psychoeducational activities can be conducted with university students to nurture their meaning in life. also, activities can be organized to increase the subjective well-being of university students so that their search for meaning in life can be supported. in the current study, significant correlations were found between meaning in life, social, emotional, and psychological well-being. in this regard, organization of activities to improve the psychological well-being of university students can contribute to their search for meaning in life. the current study has several limitations that need to be taken into account when interpreting these results. firstly, participants were self-selected students studying at a state university, thereby may not be a better representative of the general population. due to the nature of covid- which imposes people to physically and socially distance from one another ), we collected data using an online survey. however, limitations exist in internet data collection as it only encompasses internet users. next, though using various self-report measures of mental health, wellbeing, and meaning in life was fruitful in obtaining a broader picture of complete mental health, there may be some factors affecting the reliability of current findings such as social desirability. future research should use methods that reduce self-report recall biases. additionally, this study was performed using a cross-sectional design, and longitudinal research could therefore offer additional insights into the associations between the variables. finally, these findings should be iterated in more countries and cultures, with diverse samples as people may have different views of meaning in life and well-being. in conclusion, the results suggest that meaning in life can explain increases in positive mental health and decreases in negative mental health. meaning-centered intervention programs can be utilized in future research and practice to make changes in one's lives and promote their complete psychological functioning. conflict of interest the authors declare that they have no conflicts of interest. ethical approval all procedures performed in studies involving human 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publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -nxbadlal authors: moon, katie title: understanding the experience of an extreme event: a personal reflection date: - - journal: one earth doi: . /j.oneear. . . sha: doc_id: cord_uid: nxbadlal mental models, which include our assumptions about how the world works, influence how we experience extreme events, such as the australian bushfires. in turn, they can be altered by those experiences. understanding (changes to) our mental models can help communities plan for, and recover from, extreme events. the year has seen some significant changes across our social, ecological, and economic landscapes. two events stand out: the australian bushfires, which burned an area in excess of , km and killed more than one billion vertebrates; and the coronavirus disease (covid- ) pandemic, which has infected people in almost every country in the world, closed national borders, and brought economies to a standstill. i have had ''living contact'' with both of these phenomena. on new year's eve , a large fire that had been moving through the bushland of the great dividing range rapidly changed course, putting our coastal township under imminent threat. with little warning, the fire sped down from the range, incinerating much of our nearest town and threatening our own. the sky changed from an eerie yellow to pitch black within a matter of hours. we were surrounded by fire; we had no possibility of escape and had to wait for whatever came. having never experienced a bushfire of this magnitude before, i was filled with an almost unmanageable level of fear as to what was to come, what i was about to witness, and whether i would survive. with the fire several hundred meters from our home, a southerly change arrived, sparing our community but devastating those to the north of us. before we had even caught our breath, bushfire-affected communities were experiencing another extreme event: the covid- pandemic. as a social scientist, i have observed many similarities between these two extreme events. although they are clearly very different phenomena, they both serve to challenge how we see the world: what assumptions we make, what we take for granted, and how we behave. here, i use my personal experiences to explore these phenomena and offer a research pathway to help us ''make sense'' of extreme events through an understanding of mental models. sense making is an important element of planning for, and recovering from, extreme events and serves to improve the resilience of social-ecological systems. how we ''experience'' through our mental models mental models are the lenses through which we experience a phenomenon. to illustrate, in the aftermath of the fires i was speaking with a friend. i explained to him that within my mental models i held an assumption that my government would provide me with a certain level of protection and security. yet, when the fires reached our town, no one was here: no fire fighters, no aerial support, no police, no one telling us whether to stay and defend or to evacuate. the fires had extended beyond the government's capacity to protect everyone. we had no power, no telecommunications, and no radio and so had no knowledge of what was taking place around us. i experienced aloneness and insecurity. my friend, who grew up in africa, explained that in his mental models, he does not assume that the government will provide protection or security. as a result, he suggested that he would not have necessarily experienced the broader social-psychological effects of the fires in the same way as i did. his observation was useful in demonstrating that a person's mental models will shape the nature of their experience. a mental model is a metaphor that describes the small-scale model(s) that our minds use to explain how (a part of) the world works. these models, which can be elicited through a variety of methods, reveal how people organize and operate concepts cognitively. mental models comprise two components. the first is a structure component, which includes a person's knowledge, values, beliefs, and aspirations. the second is a process component, which is the operation of the model and explains how a person reasons, makes decisions, behaves, and filters and interprets information. , mental models are incomplete representations of ''reality;'' they are context dependent and can therefore change over time through learning and experience. , what has been interesting to observe during both the bushfires and the covid- pandemic is the extent to which a phenomenon can change our mental models to influence how we subsequently make decisions and behave. phenomena of the magnitude of the australian bushfires and the covid- pandemic are seismic in their power to destabilize how those who experience them see the world. by way of example, our experiences of the fires were characterized by uncertainty (e.g., a lack of predictability of the fires and of communications), isolation (e.g., main access routes were closed for days, weeks, and even months), the unavailability and rationing of resources (e.g., food supplies, generators, battery-operated devices, and batteries), the maintenance of order by riot police, a reduction and loss of business (particularly tourism trade), and a loss of important parts of our world (e.g., family and friends, homes, businesses, and ecosystems). many people were in shock as to how quickly the world they knew could be transformed into something unrecognizable. these experiences, which many are facing with covid- , can cause us to question the assumptions of our mental models. the assumptions within our mental models can appear extraordinarily fragile in the face of extreme events. for example, many people assumed that the spread of fires could be predicted with a sufficient degree of certainty, that fires could be brought under control through various management techniques, and that towns would be protected. the day before new year's eve, for instance, many locals were discussing a fire-spread prediction map that did not have our town in either the fire or ember attack zone. as a result, many people did not make preparations for an imminent threat. the fires had been ''around us'' for months, so although people were aware of the location of the fire fronts, they were not necessarily preparing to come under immediate attack. a number of assumptions (e.g., that we can rely on prediction maps) were therefore challenged during the australian bushfire season. the unprecedented fires, quite simply, were unpredictable and uncontrollable and could not be understood through the lens of existing assumptions despite the incredible efforts of the rural fire service. the importance of looking at assumptions relates to our expectations of how a system will respond to an event. the more incorrect our assumptions are, the less accurate our predictions and expectations of outcomes and, potentially, the more destabilizing the experience will be. to illustrate, many people in fire-affected communities held certain assumptions about the function of their households, communities, and governments. the experience of the fires challenged those assumptions. for instance, many of us became aware of our vulnerability to a lack of predictability, our dependence on the viability of the road network, the weaknesses in the structure of our supply chains, and the fragility of peace and order-but also the immense power of social bonds. these experiences can transform our mental models with implications for how we behave. behavioral changes of people within bushfire-affected communities could be observed with the onset of the covid- pandemic. after the new year's eve fires that burned much, but not all, of our region, we continued to face the threat of fire until mid-february. during this time, many people were wracked with indecision and second guessed themselves (e.g., should i evacuate or not?); the immediate and confrontational nature of the experience left many feeling uncertain as to what was the best course of action. we were panicked. i have observed that these experiences have resulted in a change in how quickly it becomes possible to make decisions in the face of other extreme threats. for example, although the australian government initially recommended that children continue to attend school, many, including my partner and i, made the early decision to home school their children to reduce the risk of viral transmission (well before the nsw government eventually encouraged parents to keep their children at home). we acted swiftly and with conviction on the basis that the responsibility for our own health, and thereby the health of others, lay with us. we no longer depended on others to make those decisions for us. certainly this decision was informed by the urgent warnings of italian citizens; i got the sense that they, like me, had transformed mental models of (parts of) the world as a result of their experience with covid- . i interpreted their online warnings as a message: ''make no assumptions about the certainty and security of your world; do not assume that the world as you know it will be the world as it is.'' in conversation with others in my community, we feel that transformations of our mental models as a result of the fires have somehow made us more prepared for the social-economic changes that have accompanied the covid- pandemic. a research pathway to ''making sense'' of extreme events i would like to share some thoughts on a research pathway that could help with making sense of the extreme events that many have already experienced and that many more will come to experi-ence in our climate-affected, globalized world (see table ). what this pathway offers is an opportunity to explore how our social systems respond to extreme events and, importantly, why. such explorations can illuminate how people make decisions and behave and the consequences for their preparedness and resilience both individually and collectively. first, we could seek to apply methodologies that have been designed to examine the lived experience, such as phenomenology. this methodology explores how a person ''makes sense'' of an experience. importantly, the focus is on understanding the experience independently of existing knowledge, assumptions, or expectations, particularly those of the researcher. , in other words, the researcher seeks to understand the phenomenon from the point of view of those who have experienced it by looking for patterns and relationships that reveal its unique meaning to the participants. this approach involves setting aside the meaning systems that we have inherited and asks us to question what we have ''taken for granted'' about our social world through processes of reflection. for example, i continue to re-live a distinct moment from new year's eve: i looked at up at the black sky, felt the panic in the air, and thought, ''i might die.'' my hands were shaking, and i felt nauseous. i was experiencing the phenomenon immediately; nothing before or after really mattered in that moment. on reflection, that moment pointed to the illusory nature of the construct of ''control.'' i experienced a sense of futility-we had prepared our house and belongings, and yet we were surrounded by fire, and all escape routes were closed; we had no alternatives to choose among as we came under threat. i remember looking around and thinking, ''how have i ended up in a position in which i have no control?'' people who had escaped the fire front and were seeking refuge in our town provided harrowing accounts of what they had just seen-observing their helplessness and fear further eroded any sense of my own control. i was forced to question the extent of my ability to control anything in my world in that moment. this example seeks to demonstrate that phenomenological analysis not only describes our systems of meaning but also provides opportunities to reinterpret them in ways that can be more complete, reimagined, or new entirely. the value of the methodology, then, is in creating the space for an honest and critical examination of our lived experiences and the implications for how we subsequently see, and behave in, the world. second, we could explore opportunities to apply methods that reveal how a person experiences a phenomenon on the basis of their pre-existing mental models. what is important to remember here is that the analysis is retrospective: ''it is reflection on experience that is already passed or lived through.'' questions, therefore, need to account for the retrospective nature of the knowledge in exploring the mental models at the time of the experience (table ) . a range of methods could be suitable in eliciting the mental models, including open or semistructured interviews, walking interviews, and even focus groups. what this approach permits is an understanding of how and why an individual experienced a phenomenon in the way they did and how that experience might be different or similar to those of others. third, we could examine the suitability of methods to understand the effects of the experience of the phenomenon on a person's mental models. the same methods described above could be used, but instead the questions should focus on the extent of change as a result of the experience (table ) . we move, therefore, from understanding, exploring, and describing to a deeper interrogation of experience. this approach fits with the tradition of phenomenology, which has a ''critical spirit'' and seeks to discover new ways to construct understandings by assuming that the human world is not predetermined but rather open for discovery and the emergence of new significance. by extending our research to explore how people's mental models shift and transform as a result of extreme events, we can support individuals and communities more effectively in their preparation and, crucially, their recovery. life is different on the ''other side'' of an extreme event. certainly that has been my experience and appears also to be the narrative in the context of covid- : do not expect life to ''return to normal'' once the threat has diminished. it is critical that we understand not only what is objectively different (e.g., interest rates, business structures, and operations) but also what is subjectively different. how do people see themselves and the world differently in the aftermath of an extreme event, and what are the implications of these changes? such un-derstandings can reveal both the preparedness and the vulnerability within our communities to cope with extreme events in the future. unprecedented burn area of australian mega forest fires a practical guide to using interpretative phenomenological analysis in qualitative research psychology mental models and human reasoning mental models for conservation research and practice mental models: an interdisciplinary synthesis of theory and methods a moment of mental model clarity: response to the implementation crisis in conservation planning: could ''mental models'' help? qualitative research & evaluation methods, third edition (sage) the foundations of social research: meaning and perspectives in the research process personal control over aversive stimuli and its relationship to stress researching lived experience: human science for an action sensitive pedagogy shared personal reflections on the need to broaden the scope of conservation social science the phenomenological focus group: an oxymoron? thank you to all the firefighters and support staff who assisted during the australian fire season. thank you to all who donated to and supported our communities. thank you to my community, particularly t. brewer, m. foley, and j. berry; to c. bingham for the education; to my colleagues, particularly d. blackman, c. cvitanovic, and d. biggs; and to molly and william for keeping me focused on what's important. key: cord- -tnde jp authors: jewell, jennifer s; farewell, charlotte v; welton-mitchell, courtney; lee-winn, angela; walls, jessica; leiferman, jenn a title: mental health during the covid- pandemic in the united states: online survey date: - - journal: jmir form res doi: . / sha: doc_id: cord_uid: tnde jp background: the covid- pandemic has had numerous worldwide effects. in the united states, there have been . million cases and nearly , deaths as of october , . based on previous studies of mental health during outbreaks, the mental health of the population will be negatively affected in the aftermath of this pandemic. the long-term nature of this pandemic may lead to unforeseen mental health outcomes and/or unexpected relationships between demographic factors and mental health outcomes. objective: this research focused on assessing the mental health status of adults in the united states during the early weeks of an unfolding pandemic. methods: data was collected from english-speaking adults from early april to early june using an online survey. the final convenience sample included us residents. the -item survey consisted of demographic questions, mental health and well-being measures, a coping mechanisms checklist, and questions about covid- –specific concerns. hierarchical multivariable logistic regression was used to explore associations among demographic variables and mental health outcomes. hierarchical linear regression was conducted to examine associations among demographic variables, covid- –specific concerns, and mental health and well-being outcomes. results: approximately % ( / ) of the us sample was aged ≥ years. most of the sample was white ( / , %), non-hispanic ( / , %), and female ( / , %). participants reported high rates of depression ( / , %), anxiety ( / , %), and stress ( / , %). older individuals were less likely to report depressive symptomology (or . , p<. ) and anxiety symptomology (or . , p<. ); in addition, they had lower stress scores (– . points, se . , p<. ) and increased well-being scores ( . points, se . , p<. ). individuals who were no longer working due to covid- were . times more likely to report symptoms of depression (p=. ), had a . -point increase in stress (se . , p=. ), and a . -point decrease in well-being scores (se . , p=. ) compared to individuals who were working remotely before and after covid- . individuals who had partial or no insurance coverage were - times more likely to report depressive symptomology compared to individuals with full coverage (p=. and p=. , respectively). individuals who were on medicare/medicaid and individuals with no coverage were . and . times more likely to report moderate or severe anxiety, respectively (p=. and p=. , respectively). financial and food access concerns were significantly and positively related to depression, anxiety, and stress (all p<. ), and significantly negatively related to well-being (both p<. ). economy, illness, and death concerns were significantly positively related to overall stress scores (all p<. ). conclusions: our findings suggest that many us residents are experiencing high stress, depressive, and anxiety symptomatology, especially those who are underinsured, uninsured, or unemployed. longitudinal investigation of these variables is recommended. health practitioners may provide opportunities to allay concerns or offer coping techniques to individuals in need of mental health care. these messages should be shared in person and through practice websites and social media. the covid- pandemic has produced over million confirmed cases and over . million confirmed deaths worldwide as of october , [ ] . of these, nearly . million cases are in the united states, with nearly , deaths [ ] . in addition to health impacts, many have raised the alarm about the potential for a widespread global mental health crisis as a result of the pandemic [ ] [ ] [ ] [ ] . specific groups may be at increased risk for adverse mental health outcomes, such as frontline health care workers [ ] and those that have experienced illness or death of family, friends, or coworkers. many more are likely to experience distress as a result of economic hardship, disruption to social networks, and work-and school-related changes due to the protracted crisis. elevated rates of depression and anxiety have been documented following stressors such as disease outbreaks, including the - ebola crisis in west africa, among caretakers, survivors, their immediate contacts, and others [ , ] . in addition, epidemics such as sars and hiv have been associated with depression and other mental health concerns among various groups [ ] [ ] [ ] [ ] [ ] [ ] . the current pandemic is likely to be associated with similar mental health outcomes, as a result of potential exposure to stressors including loss of loved ones, economic hardship, social isolation, and childcare responsibilities following school and day care closures. countless businesses across the united states closed in an attempt to protect workers, limit transmission of the coronavirus, and allow health care systems to keep pace with the needs of those requiring hospital care. with the exception of essential services, much of the economy has come to a virtual standstill, resulting in unprecedented rates of unemployment [ ] . financial struggles, including job loss and food insecurity, are known risk factors for mental illness, particularly anxiety, depression, and suicide [ , ] . in most us states, nonessential workers have been required to stay at home for several weeks. many states have had stay-at-home orders in place for longer periods of time. although there is an easing of movement restrictions in some areas within the united states, many people are still concerned about the potential safety risks of resuming prepandemic levels and types of activities. as a result, so-called "social distancing" continues for many in the united states. physical distancing requirements (eg, social distancing) have the potential to limit physical and social contact, disrupt prepandemic social networks, and undermine the potential for social support at a time when it may be needed most. this may result in an increase in loneliness and social isolation. across numerous studies, social isolation has been associated with increased morbidity and mortality, with an increase in coronary heart disease, stroke, and poor mental health outcomes such as depression and anxiety [ ] [ ] [ ] [ ] [ ] . the increase in financial and familial struggles for some families may have exacerbated the negative effects of strict social distancing measures and overall trauma. although studies examining the mental health impacts of covid- are limited, findings from a few recent studies indicate that many in the united states are experiencing significant and worsening mental health difficulties during the pandemic [ ] . a review of the emerging literature regarding the effects of the pandemic suggests that symptoms of anxiety and depression are common [ ] . in one study [ ] , which used a representative sample and compared recent mental health concerns to those in , large increases in mental health distress were noted. younger people, those with children in the household, married individuals, and asians appeared to be faring worse than others [ ] . authors suggested these findings may reflect economic hardship, but more research is needed to understand factors contributing to greater difficulties in some groups than others. the current study examines demographic differences in mental health and well-being outcomes and specific sources of concern that impact these outcomes among a us sample of adults surveyed between april and june , , immediately following business closures and movement restrictions. this study may bring to light additional factors related to mental health during the pandemic and fill gaps in the current literature. specifically, several covid- -specific concern-related items that have not been previously assessed were included in the current analyses. these findings have the potential to inform current intervention efforts as well as new initiatives, with the potential to mitigate suffering and bolster resilience during the ongoing pandemic. the mental health and wellbeing survey during covid- pandemic received ethical approval from the colorado multiple institutional review board (comirb protocol # - ). survey data was collected between april and june , . a snowball sampling technique was used. this survey was advertised on facebook and instagram via paid targeted advertising. in addition, it was sent out via listservs and other media including centers for disease control and prevention (cdc) prevention research centers, american public health association mental health section, colorado public radio, university of colorado research announcements, and the university of south florida. study data were collected and managed using redcap electronic data capture tools hosted at the university of colorado [ ] . redcap (research electronic data capture) is a secure, web-based application designed to support data capture for research studies, providing the following features: ( ) an intuitive interface for validated data entry, ( ) audit trails for tracking data manipulation and export procedures, ( ) automated export procedures for seamless data downloads to common statistical packages, and ( ) procedures for importing data from external sources. participants consented digitally before beginning the survey. additionally, participants in the initial survey were given the opportunity to opt in to future surveys to collect longitudinal data. a participation incentive in the form of a drawing for one of two $ gift cards was offered. adults aged ≥ years were eligible to take the english-language survey, regardless of country of residence. there were no exclusion criteria beyond ability to provide consent. although data was collected from an international sample initially, most of the participants were residing in the united states. as a result, only data from the us subsample is included in the present analyses. the final us sample consisted of individuals. the -item survey consisted of demographic questions, mental health and well-being measures, coping mechanisms, and questions gauging covid- -specific concerns. demographic questions included age, race/ethnicity, gender, work status, household size, and insurance coverage. the survey also included four mental health and well-being scales measuring well-being, depression, anxiety, and stress. the short warwick-edinburgh mental wellbeing scale (swemwbs) was used as a continuous measure of well-being. it has high internal consistency and convergent validity with other measures of life satisfaction and physical and mental health (α=. in this sample). the swemwbs has a range of - , with higher scores indicating higher well-being [ ] . the patient health questionnaire- (phq- ) was used as a brief measure of depression (α=. in this sample). the phq- has a sensitivity of % and a specificity of % for major depression. the phq- has a range of - and was dichotomized for analyses using a cutoff score of ≥ [ , ] . generalized anxiety disorder (gad) was assessed using the gad- , which has a sensitivity of % and a specificity of % (α=. in this sample). the gad- has a range of - , and moderate or severe anxiety was based on a cut-off of ≥ [ ] . lastly, stress was assessed using a validated -item continuous measure with response options ranging from "not at all" to "very much" stress "these days" (elo stress-symptoms item). this stress item has demonstrated construct, content, and criterion validity for group-level analysis [ ] . the survey included a coping checklist, comprised of behavioral items with an additional "other" option, to ascertain which types of coping were most common (eg, exercise, engaging with media, engaging remotely with family/friends). the survey items examining covid- -specific concerns included questions about personal financial impact, food security, economic impact, and risk of serious illness or death (in participants or others known to participants) related to covid- . questions were phrased in the following manner: "how concerned are you about... [the financial impact current events may have on your family]?" data were exported from redcap into spss (version ; ibm corp) for analyses. data cleaning included testing of assumptions, exploration of outliers, and missingness for all key variables. as all key variables had less than % missing data and data were missing completely at random (χ = . , p=. ), listwise deletion was used in all analyses. univariate and bivariate analyses were conducted. two proportion z tests were also used to calculate differences between responses (%) to the phq- and gad- and national prevalence data. an independent sample t test was run to compare the sample average for the warwick wellbeing score with a nationally representative sample. two hierarchical multivariable logistic regression models were run (logistic regression models and ) to explore associations among demographic variables, depression (not depressed versus depressed), and anxiety (no or mild anxiety versus moderate or severe anxiety) outcomes. hierarchical regression was used to investigate if specific sources of concern (eg, financial concern, illness-related concern) were related to the outcome measures after controlling for demographic characteristics of the analytical sample. for categorical variables, well-established cutoffs based on representative us samples were used. all demographic variables were added simultaneously to each model, after which unique sources of concern were entered into models (logistic regression models and ) to see which sources of concern predicted depression and anxiety outcomes after controlling for demographics. r values, odds ratios, and p values for logistic regression models are presented. next, two hierarchical linear regression models were run (linear regression models and ) to explore associations between demographic variables and stress and well-being outcomes. in total, unique sources of concern were entered into models (linear regression models and ) to see which sources of concern predicted stress and well-being outcomes after controlling for demographics. unstandardized coefficients, p values, and adjusted r values are reported for all linear regression models. alpha (α) was set at . . linear regression models for the well-being and stress outcomes are presented in table . an increase in age decade was associated with a . -point decrease in stress score (se . , p<. ) and a . -point increase in well-being score (se . , p<. ). on average, individuals who did not have insurance reported a . -point higher stress score (se . , p=. ) and a . -point lower well-being score (se . , p<. ). no longer working due to covid- was associated with a . -point increase in stress score and . -point decrease in well-being score compared to individuals who were working remotely before and after covid ("no change" group; se . , p=. ; se . , p=. ). males also reported significantly lower stress scores compared to females (b= . , se . , p<. ). financial concerns and food access concerns were significantly and positively related to depression, anxiety, and stress (all p<. ) and significantly negatively related to well-being (both p<. ). economy-, illness-, and death-related concerns were significantly and positively related to overall stress score after controlling for all demographic variables (all p<. ). additional analyses were considered, including investigating the effects of race/ethnicity and parenthood status. the cell sizes for these variables were too small to conduct analyses. table . logistic regression models showing associations between depression (models and ), anxiety (models and ), demographic variables, and sources of concern (n= ). the imposed social distancing experienced by many throughout the united states undoubtedly contributed to numerous shortand long-term negative effects within the population. this survey aimed to identify the impact of the covid- pandemic and imposed social distancing on mental health among us residents within a small window of time during which many businesses were closed and many individuals were out of work. based on the findings associated with this convenience sample, when compared to prepandemic representative population-level data in the united states, it appears that mental health declined overall during the late spring of . prevalence rates of both depressive symptoms and anxiety symptoms were notably higher than national prepandemic averages. in addition, mental well-being significantly decreased, and stress levels were elevated in this sample. these findings support early evidence that the effects of the pandemic on mental health are significant [ ] . the findings from the regression analyses suggest that age may be an important factor in considering mental health impacts of the pandemic. as age increased, anxiety symptoms, depression symptoms, and stress decreased, and well-being increased. this effect may be explained by stress on younger individuals due to inconsistent income or parenting-related obligations; however, these relationships could not be analyzed due to small cell sizes. based on a review of the limited literature specifically related to the covid- pandemic, rajkumar [ ] found that older adults were at greater risk for mental health concerns [ ] . no other studies we reviewed found a relationship with age. further research should be conducted to determine mental health risks relative to age and associated factors during the covid- pandemic. findings from this study suggest loss of work due to pandemic-related closures greatly increased the odds of depression symptoms when compared to individuals who did not experience a change in their employment (were working remotely both before and after closures began). loss of employment was also related to increased stress levels and decreased mental well-being. this could indicate a segment of the population that may require additional support to overcome mental health challenges during the pandemic. economic crises have been tied to poor mental health outcomes in numerous studies [ , ] . employment, in contrast to unemployment, has been linked to decreased mental illness, including depression and anxiety, and increased mental well-being [ ] . job instability, including moving from a permanent position to a temporary position, has been linked to increased mental illness [ ] . public health officials should make targeted efforts to reach out to the segment of the population that completely lost the ability to work during social distancing regulations. these individuals may need aid that extends beyond financial support. partial and no insurance coverage was associated with increased odds of depression symptoms when compared to fully insured individuals. this finding supports previous evidence that increased health care coverage reduces the prevalence of undiagnosed and untreated depression [ ] . individuals with limited health coverage also had higher stress scores and lower well-being scores. a similar effect was seen with moderate to severe anxiety. this finding was particularly pronounced in the uninsured population. the effects of partial or no insurance coverage on mental health may be exacerbated by the circumstances of the pandemic. those with no insurance demonstrated extremely high odds of anxiety symptoms. this is likely related to concern about what would happen to them if they contracted covid- . practitioners working with uninsured and partially insured individuals should take note of potentially decreased mental health in this population. although these practitioners may not have the ability to affect their patients' insurance status or concerns about the potential financial burden of contracting covid- , they do have the opportunity to encourage low-or no-cost coping methods that may decrease depressive and anxiety symptomatology. several other factors demonstrated relationships with mental health. males reported significantly lower stress levels than females. this is consistent with findings on gender and stress [ ] . this difference in stress levels may be due to gender differences in coping with stressful situations and differences in hormonal responses to stressful events [ ] . increased family financial concern and family food access concern were positively related with depression symptoms, anxiety symptoms, and stress, and negatively related to well-being. in addition, concern about the economy, illness-related concern, and death-related concern were positively related to stress scores. the financial concern and food security findings are consistent with previous work investigating this relationship [ , ] . each of the relationships between the concern items and mental health variables is consistent with expected outcomes from the covid- pandemic [ ] . practitioners may wish to ask their patients about specific concerns that they may be experiencing during this time. using a sliding scale for medical fees and having referrals and information about different types of aid available (eg, food banks and local, state, and federal funds) may reduce the mental burden on some individuals. practitioners are also in the best position to convey accurate information about covid- risk status and effective protective measures. information of this type can be conveyed in person or online through practice websites and social media. this reliable information may counteract the concern of illness and death and reduce poor mental health outcomes. there are noteworthy limitations to this study. the convenience sample was primarily insured, non-hispanic, white, and female, which may have led to results that are not generalizable to the broader population of us adults. minority populations tend to experience the effects of trauma to a greater degree than others. given the results seen in this study in a non-hispanic white population that is primarily insured, it is reasonable to assume that minority populations may be impacted to an even greater degree than what was demonstrated in this study. particular care should be taken to measure and address these concerns in future studies. in addition, due to the small number of african americans in this sample, we were not able to explore the relationship between race and mental health, a limitation that should be prioritized for exploration in follow-up research. in addition, the sample did not include a representative percentage of young people or individuals with children. given the age effects in this study, further investigation is encouraged to determine the effect of age on mental health outcomes during the pandemic. the results of this study are based on a comparison with prepandemic norms, which may not be representative of the morbidity of these mental health conditions in peripandemic or postpandemic times. functional impairment was not measured. therefore, assumptions about the impact of negative mental health symptomatology in the peripandemic period cannot be made. furthermore, the survey was conducted online, which likely inadvertently excluded individuals that do not have access to or are uncomfortable with the internet. the strengths of this study include the large sample, which consisted of respondents from of states in the united states. this survey was also developed and launched early in the pandemic's course through the united states. therefore, it likely captured early mental health responses that later surveys may not have captured. these responses included both mental health struggles and positive mental health indicators. this study was designed with a follow-up in mind. respondents to this survey were asked if they would be willing to participate in a follow-up survey at a later date. this will allow for longitudinal data collection at multiple time points as social distancing restrictions change throughout the united states. our findings suggest that many us citizens, particularly non-hispanic, white, insured individuals, are experiencing high stress, depressive, and anxiety symptomatology. practitioners, including health care workers and mental health specialists, can be a resource for those struggling with mental health concerns during the pandemic. these messages should not only be made in person, but also through practice websites and social media accounts. the overwhelming amount of information available to the public regarding covid- makes it difficult to delineate accurate information from inaccurate information [ ] . practitioners have a preexisting rapport with their patients that they should use to shift the balance toward accurate information. this patient-provider relationship may engender trust that does not exist with larger health or government entities. practitioners should capitalize on this rapport to convey accurate, timely information regarding risk factors, protective measures, coping techniques, financial relief, and food banks. policy makers should encourage growth in areas of mental health support that are most feasible during this time. telemental health, for example, has been shown to be highly effective, cost-efficient, and accessible, especially in isolated communities [ ] . online mental health assessments and self-directed mental health interventions have also been widely introduced in china, with their effectiveness remaining to be seen [ ] . future research should continue to track the mental health effects of the pandemic as it progresses. there may be future waves of illness that impact social distancing recommendations and requirements. these, in turn, may impact mental health. longitudinal investigation of these effects is recommended. future studies should make concerted efforts to obtain a representative sample. representative state-specific samples are available through various entities for a fee. in addition, specific outreach to underrepresented populations is recommended. knowledge of these fluctuations in 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lancet psychiatry this study was supported by nih/ncrr colorado ctsi grant number ul rr . its contents are the authors' sole responsibility and do not necessarily represent official national institutes of health (nih) views. research, is properly cited. the complete bibliographic information, a link to the original publication on http://formative.jmir.org, as well as this copyright and license information must be included. key: cord- -mf b p authors: buckley, ralf; westaway, diane title: mental health rescue effects of women's outdoor tourism: a role in covid- recovery date: - - journal: ann tour res doi: . /j.annals. . sha: doc_id: cord_uid: mf b p mental and social health outcomes from a portfolio of women's outdoor tourism products, with ~ , clients, are analysed using a catalysed netnography of > social media posts. entirely novel outcomes include: psychological rescue; recognition of a previously missing life component, and flow-on effects to family members. outcomes reported previously for extreme sports, but not previously for hiking in nature, include psychological transformation. outcomes also identified previously include: happiness, gratitude, relaxation, clarity and insights, nature appreciation, challenge and capability, and companionship and community effects. commercial outdoor tourism enterprises can contribute powerfully to the wellbeing of women and families. this will be especially valuable for mental health recovery, following deterioration during covid- coronavirus lockdowns worldwide. leisure tourism is a discretionary activity to improve individual wellbeing. worldwide, poor mental health and wellbeing impose large social and economic costs on human civilisations (mcdaid, park, & wahlbeck, ; patel et al., ) . these costs amounted to ~ % of global gnp prior to the / covid- coronavirus pandemic. they are increasing currently through covid- lockdown, isolation and quarantine measures (brooks et al., ) . by improving wellbeing, tourism can reduce these costs. this generates an economic value within the healthcare sector, additional to that within the tourism sector. in particular, exposure to nature generates a substantial and diverse set of mental health benefits (bratman et al., ; frumkin et al., ) . these confer an additional economic value on national parks, estimated at > us$ trillion p.a. worldwide . this health services value is generated via outdoor nature and adventure tourism and recreation (buckley, (buckley, , . it is at least ten times larger than the direct economic value of tourism in parks (balmford et al., ) . the health services value of nature and adventure tourism and recreation is already embedded in the structure of modern human societies and economies. if people did not engage in these activities as discretionary self-funded leisure, the costs of poor mental health would increase, by an estimated additional . % . these additional costs are indeed now being incurred, as one component of the social and economic costs of covid- lockdowns. costs include treatments, carers, lost workplace productivity, and increased antisocial behaviour, both public and domestic. domestic violence, one of the key cost components, has already increased as one result of covid- family confinement (brooks et al., ) . irrespective of the current covid- pandemic, women worldwide are disproportionately susceptible to many of the causes of poor mental health (halliday, kern, & turnbull, ; hodes & epperson, ) . this occurs through: domestic violence and table disciplinary paradigms relevant to tourism as therapy. practice paradigm research paradigm wellbeing tourism, eg spas, yoga individuals travel to buy spa, yoga or other wellness experiences. tourism: providers capitalise on individual discretionary expenditures to improve self-perceived wellbeing medical tourism individuals travel for mainstream or cosmetic medicine, to get better price, quality, equipment, safety, legality. tourism business: medical facilities as attraction. individual discretionary choices, funding, outcomes. nature and adventure tourism individuals travel to watch wildlife, see scenery, experience emotions, achieve adventure goals. tourism: interactions between commercial tour operators and their clients, including geography, motivations, satisfaction, etc. leisure, stress reduction some discretionary leisure activities can reduce stress, eg from the workplace. r. buckley and d. westaway annals of tourism research ( ) tourism and wellbeing; medical tourism; leisure and wellbeing; outdoor recreation; outdoor education; nature and mental health; therapeutic landscapes; healthcare policy; the economics of nature conservation; and women's outdoor recreation and mental health specifically. in tourism, the most relevant theoretical framework has been that of wellbeing, quantified through descriptive quality-of-life measures (lengieza et al., ; uysal, sirgy, woo, & kim, ) . this is a heavily studied field, with several recent reviews (pyke, hartwell, blake, & hemingway, ; smith & diekmann, ; uysal et al., ) . there is also a parallel but more prescriptive field known as positive psychology (coghlan, ; filep & laing, ; nawijn & filep, ; vada et al., ) . all this research has focussed on healthy individuals, not medical patients. there are distinct sets of research on spa, retreat, yoga and wellness tourism (bowers & cheer, ; chen & li, ; gabor & oltean, ; pyke et al., ) ; and on medical tourism (hoz-correa, munoz-leiva, & bakucz, ; mathijsen, ) . those, however, do not address the social and mental health outcomes of tourism generally. leisure research argues that non-work discretionary activities reduce stress (denovan & macaskill, ) , and improve quality of life (iwasaki, ; wensley & slade, ) , through preventive and therapeutic pathways (fenton et al., ; l. fenton, white, gallant, hutchinson, & hamilton-hinch, ; l. fenton, white, hamilton-hinch, & gilbert, ; y. iwasaki et al., ; y. iwasaki, coyle, & shank, ) . non-commercialised outdoor recreation, including exposure to nature, can yield a wide range of health benefits, both physiological and psychological (biedenweg, scott, & scott, ; bratman et al., ; davies, ; kondo, jacoby, & south, ; twohig-bennett & jones, ) . those benefits include reduced incidence of medically diagnosed syndromes, such as clinical depression and alzheimer's and parkinson's diseases (hansson et al., ; svensson et al., ; tomas, martina, ulf, stefan, & tomas, ) . critically, they include marginal gains beyond those of exercise alone (araújo, brymer, brito, withagen, & davids, ; bélanger et al., ; blondell, hammersley-mather, & veerman, ; chekroud et al., ; clough, mackenzie, mallabon, & brymer, ; elbe, lyhne, madsen, & krustrup, ; frühauf et al., ; horowitz et al., ; niedermeier, einwanger, hartl, & kopp, ; pasanen, white, wheeler, garrett, & elliott, ; white et al., ) . mental health benefits have been shown for many different types of adventurous outdoor recreation (araújo et al., ; buckley, a; collins & brymer, ; frühauf et al., ; hansson et al., ; hetland, kjelstrup, mittner, & vitterso, ; holland, powell, thomsen, & monz, ; holmbom, brymer, & schweitzer, ; morris & scott, ; niedermeier et al., ; roberts, jones, & brooks, ; white et al., ) . benefits have also been demonstrated for contemplative outdoor activities, such as forest walks (chen, yu, & lee, ; hansen, jones, & tocchini, ; kobayashi et al., ; lyu et al., ; morita et al., ; oh et al., ) . there is a parallel field of geographical research on therapeutic landscapes (bell, foley, houghton, maddrell, & williams, ) . research in outdoor recreation has focussed on healthy individuals, rather than clinically diagnosed patients, though a few studies have compared healthy and unhealthy subjects (ower et al., ) . mental health benefits from activities in outdoor nature have been summarised in several recent reviews and meta-analyses (bratman et al., ; buckley & brough, a; frumkin et al., ; kondo et al., ; oh et al., ; seymour, ; shanahan et al., ) . benefits can occur across a wide range of mental health parameters, environments (biedenweg et al., ; wyles et al., ) , and personality types . they may have considerable economic value . in the health sector, the fundamental paradigm is the diagnosis and treatment of patients who present with illnesses. only the public health subsector includes preventive measures for individuals currently in good health, as well as therapies for those who are not. poor health, mental as well as physical, is considered to incur substantial social and financial costs, at all scales from individual to national economy (mcdaid et al., ; patel et al., ) . considerable effort is devoted to measuring and minimising each component of these costs. implementation of nature-based therapies in mental healthcare lags research (buckley & brough, b; buckley, brough, & westaway, ; van den berg, ) . prescriptible therapies need design, dose, and duration of individual treatments and entire courses of therapy, in relation to symptoms, severity, and patient personality. quantitative data on design-dose-duration-response relationships are not yet available (bratman et al., ; buckley, brough, b; frumkin et al., ; shanahan et al., ) , though research has begun . prescriptible therapies need institutional systems for diagnosis, prescription, certified providers, and funding (buckley et al., ) . commercial outdoor tourism can capitalise on this by repackaging tourism products as therapies (buckley, ) . maintaining and improving mental health is valuable both socially and economically. many people are mentally languishing rather than flourishing (keyes, of the population each year experience common mental health disorders (australia institute of health and welfare, ) . treatment by prescribing opioid antidepressants has created very large secondary social costs through addiction (johnson, eriator, & rodenmeyer, ; kolodny et al., ; kolodny & frieden, ; murthy, ) . this opioid epidemic has triggered trillion-dollar litigation worldwide, and is one factor driving recent interest in outdoor therapies as alternatives. in urbanised developed nations, the total economic costs of poor mental health were estimated, prior to the covid- pandemic, at ~ % of gdp (buckley, brough, a , b australia, productivity commission, ) . costs include treatments, carers, lost workplace productivity, and antisocial behaviours (buckley et al., ) . in the longer term, costs are growing, because of increasing individual longevity, workplace stress, and childhood videophilia (cooper, ; pergams & zaradic, ; soga & gaston, ; zhang, goodale, & chen, ) . as children spend less time outdoors, this creates health costs that persist throughout adulthood (engemann et al., ; lee et al., ; stafford et al., ) . as individuals live longer in poor mental health, this imposes additional health costs through the need for mental health care and treatment over an extended period of years. currently, covid- lockdowns are increasing these costs worldwide (liu, bao, huang, shi, & lu, ; mazza et al., ; pierce et al., ; vizard, davis, white, & beynon, ; wang et al., ) . women have historically been under-represented in outdoor tourism research and practice, though there is now a growing recognition of gender differences (evenson et al., ; pohl, borrie, & patterson, ) , across the entire life course (carmichael, duberley, & szmigin, ; cosgriff, little, & wilson, ; wharton, ) . women may have different motivations and learning styles than men (kiewa, ; whittington, ) ; face different barriers and encouragements to take part in various outdoor activities (doran, schofield, & low, ; little, ; loeffler, ; mcniel, harris, & fondren, ; morris, van riper, kyle, wallen, & absher, ) ; and attach importance to different aspects and achievements (kiewa, ; nolan & priest, ) . there is also a small and recent research literature on family adventure tourism, where parents and children take part jointly (pomfret, ; g. pomfret & varley, ) . regular walking groups and programs as a form of low-key therapy, especially for women, have received particular attention recently (davies, ; duncan, gordon, & scott, ; hanson & jones, ; kelly et al., ; legrand & mille, ; marselle, warber, & irvine, ; robertson, robertson, jepson, & maxwell, ) . simply encouraging people to walk regularly, however, is ineffective (hillsdon, thorogood, white, & foster, ; ogilvie, foster, & rothnie, ) . a suite of social levers is required to achieve high take-up and repeat activity (buckley et al., ) . women may also experience different patterns in mental health than men, at all life stages. these may depend on social and cultural context as well as individual physiological factors. across all life stages, higher proportions of women than men experience depression, in a wide range of countries and societies (bale & epperson, ; halliday et al., ; hodes & epperson, ; kessler, ; lemoult & gotlib, ; salk, hyde, & abramson, ) . any measures, including outdoor tourism, that can counteract poor mental health in women specifically, thus gain particular social and economic value. all of these considerations point towards a new social importance of outdoor tourism, and a new and potentially very large market for outdoor tourism products. this has only recently been identified. buckley ( ) reanalysed previously published ethnographic datasets from a range of nature and adventure tourism products, picking out components related to mental health. outcomes included positive emotions, recovery from stress, and changed worldview. levi, dolev, collins-kreiner, and zilcha-mano ( ) conducted repeated clinical interviews, using a psychiatric rating scale, with patients diagnosed with major depressive disorders, who were voluntarily taking part in self-purchased tourism products, of various types. they found that mental health condition improved for some patients, but worsened for others. their sample was too small, and non-randomised, to identify causes of these differences. buckley ( ) conducted brief interviews with tourists visiting forest and beach parks in australia, and found that % perceived park visits as contributing to health and happiness, rather than the reverse. overall, there has been quite limited research to date on the role of tourism as a prescriptible therapy. the approach taken here differs from any of these previous studies. we analyse a portfolio of closely related and cross-marketed tourism products, offered repeatedly by the same company in multiple years and locations. we focus specifically on mental and social health outcomes perceived by participants. this appears to be the first analysis to adopt this approach. in addition, the tourism products in this portfolio are marketed principally or exclusively to women. this analysis examines effects not only on participants, but also on their families. this appears to be a novel dimension in this research field. the authors are experienced in outdoor tourism and recreation, but are not psychologists or mental health practitioners. our participants are drawn from the clientele of an australian tourism enterprise that offers three relevant products. the first consists of one-day hiking tours, now a widespread tourism product (davies, ; ower et al., ) . the second consists of multiweek wilderness hiking and trekking tours worldwide, part of the global adventure tourism sector. the third consists of three-month commercial charity challenge events (coghlan & filo, ) , run in various australian states (buckley et al., ; westaway, ) . the company has ~ , clients to date, about % of the adult female population of australia. this portfolio was selected since: (a) it is offered and repeated regularly; (b) it encompasses a wide range of durations, to maximise the opportunity to generate mental and social health changes; (c) at least for the introductory products, it is inexpensive, so that individuals can take part across a wide range of socioeconomic circumstances; and (d) the products each have entirely or largely female clientele. the methodology adopted is internet-based ethnography, known as netnography (kozinets, (kozinets, , . this is a minimallyintrusive, open-ended, qualitative methodology, analysing internet-accessible electronic text written directly by the participants themselves. such approaches are now widespread throughout the social sciences, including leisure and tourism (canavan, ; mkono & markwell, ; tavakoli & mura, ; veal, ) . they are non-invasive, and can capture a large volume of material rapidly. their main disadvantage is that the researcher does not interview the participants directly, and hence cannot use the cues of spoken or body language in interpretation, nor ask follow-up questions or probe for inconsistencies. in addition, the researcher may not share the participants' experience. the analysis used both a standard passive netnography based on social media postings, and an actively catalysed variant. for the former, the first author trawled through publicly accessible facebook® posts by clients of the company concerned. these were identified by starting with the social-media "friends" of the founder's professional page, and expanding to "friends of friends" where permitted by privacy settings. this was continued until well over individual posts had been examined, posted by several hundred different individuals, all female. many posts were responses to a video presentation (westaway, ) . we excluded posts referring only to physical fitness, and very brief posts with limited conceptual content. for the catalysed netnography, we used a -member private facebook® group, all female, maintained by tour company clients. an administrator posted an enquiry, and relayed the response posts to the first author, anonymously. the question was neutral, asking how participants' mental health, and their families', was affected by these tourism products. the enquiry outlined the research, and included consent for use of responses. this is netnography, since materials were posted on social media, visible to other group members, and analysed without interviews, exchanges, or identification. it is catalysed, since the enquiry posted by the administrator led members to post complex comments specifically in response. all text was analysed jointly using constant-comparison grounded-theory paradigms (glaser & strauss, ; stern & porr, ) . concepts were extracted, coded, and classified iteratively, to build a coding tree (buckley, b; glaser & strauss, ; stern & porr, ) . coding was checked by two independent analysts. iterations were repeated until theoretical saturation and efficient coding were achieved (aldiabat & navenec, ; buckley, b; denovan & macaskill, ; nelson, ; saunders et al., ) . netnography reveals the range of outcomes perceived by participants, but not their distribution. outcomes are not clinical assessments, but most participants' mental health concerns were sub-clinical, where their own perceptions are sufficient. therefore, this approach is a reliable first step in assessing mental and social health benefits achieved through participation in nature-based outdoor tourism. as in all netnographies, the demographic and socioeconomic characteristics of individuals posting each item are unknown unless revealed within individual posts. for this analysis, items were posted under real names, verified by the tour company. all participants were female. most are urban women with families, with a few younger members. from a tourism perspective, they are domestic rather than international clients. in the analysis, saturation was achieved rapidly. the coding tree is summarised in table . major constructs are expanded below, with illustrative quotes. posts focussed heavily on the experience and its outcomes for themselves and their friends and families, matching the aims of this study. participants referred to their overall state of health, saying that participation "definitely improved my state of mind, physical and emotional health", producing a "healthy mind, body and spirit". some added that they "gain mental strength", "feel so good", "so happy", or even an "overabundance of joy and happiness". one said: "when i have been out walking, i feel … amazing, happy, fulfilled, rich, in love, energetic, inspired, unbeatable, exhilarated, motivated, strong, clever, fit". they felt "lucky", "fortunate" and "blessed", and that they had received "a gift" or even "the greatest gift ever". they said that they took the opportunity to "immerse myself in nature" and "appreciate the beautiful surroundings". they referred to "amazing places", "beauty", "magic" and "positive energy." participants mentioned that: "i instantly feel relaxed the moment i'm out in nature", "it allows me to unwind or switch off when i need to", and that it provides "a big stress release" allowing them to "find peace" and "sleep better". some referred to the high stresses of daily life, and the need for escape: "pretty hectic .. small kids .. working .. demanding job .. getting out is my only real 'me time'"; "busy city ... stresses & strains … rat race … craving time outside". as a result, participants found that "nature gives me the answers" to "clear [my] head" so as to "find myself, redefine myself", through "'thinking' me-time", which "fills my mind with balance". participants said that taking part in these outdoor hiking tours "gives me challenges" or even "challenged me to push myself more than i would ever have thought possible". they found "strength and stamina you never knew existed in you", and that ultimately "every step ... is possible", and that "however difficult, [it is] so worth it". transformation was mentioned frequently: "life changer", "changed my life", "huge impact on my life", "it can change your life for a minute, a day, a lifetime", "that mountain called life becomes so climbable". the theme of new opportunity, or a previously missing life component, was reflected in phrases such as "missing link", "the piece of me that had been missing", "whole new world", and "you don't know how much you need nature until you take that step outside". the most powerful mental health theme was that hiking in natural surroundings with like-minded female companions had rescued them psychologically from dark and difficult times. they said that it "got me through some of my darkest times" or "brought me back from dark times", providing "a way forward when i was lost". they referred specifically to mental state, saying that it "improved my state of mind when i hit an all-time low" or "helped me regain the state of mind i felt i had lost forever". some went even further: "i don't know how i would have coped without it", "it saved my mind many times over". participants referred repeatedly to companionship, community, and support: an "amazing community of women", "powerful and nurturing", with a "big vision". they argued that "women need other women to flourish", and spoke of the "camaraderie of so many likeminded women." at a smaller and shorter scale, they mentioned "walking in nature with friends", using terms such as "friendship", "connecting", "group", "safe group" and "team". one said that she was "inspired to create my own weekly women's walking group". participants acknowledged staff of the tour company, saying "thank you for everything you do for us", and also companions: "my fellow hikers .. have taken me into their hearts". participants referred to a general improvement in their own attitudes towards their families after taking part in these products, saying that they "come home to my family from my walks feeling rested and invigorated", with "renewed positivity and resilience" and "a lot more energy and patience to give to my husband and two small kids". one said "i'm a nicer person, mother and wife when i get out in nature", and another, that her husband "definitely sees a positive effect in me". in summary, "happy mum usually equals happy family." some table coding: concepts, constructs, & key terms. mentioned that their children had followed their example: "they know i do it … they ask to go too"; "it inspires my kids to go out bushwalking"; and "my five-year-old decided to go for a run". for some, the effect flowed in the opposite direction: "my daughter inspired me", or both at once: "my daughter and i [took part] together". many of these women reported that it took some time for their husbands or partners to accept and respect it: "my husband was not happy at all at first", but now "he has got used to it". for some, this "inspired my husband to enjoy his own pursuits 'guilt-free'". for others, their husband now "encourages and supports me to get out there", and "fully supports my involvement". the overall outcome was improved family cohesion. participants said that "my family …. thinks it's amazing" and that "a family that walks together lives happily". they said their children "love it when we go on bush walks together", that "we really enjoy going for long hikes together", and that they treat "walks with our kids as special family bonding time that we treasure". the end result is a "happier more cohesive household". we identified basic themes, classified into psychological constructs and social constructs (table ) . we presented the psychological constructs in groups: happiness and gratitude; relaxation, release, and clarity; capability, transformation, and missing life components; and psychological rescue. we presented the social constructs in groups: companionship and community; family attitudes and children; and spousal support and family cohesion. this is a novel set of results, not reflecting any previous analysis. it is a different set of constructs from that identified previously for a much broader range of outdoor adventure tourism participants (buckley, ) . that previous analysis indicated that mental health outcomes of outdoor tourism could be classified into short-term emotional responses, medium term stress-recovery effects, and longer-term worldview changes (buckley, ) . below, therefore, we discuss in more detail, which of our findings are comparable to those from previous research, and which appear to be entirely new. the covid- pandemic during has created major social, economic and environmental changes, the "anthropause" (rutz et al., ) , with unknown future scale and duration. there is widespread deterioration in mental health, due to concerns over family health, loss of livelihood, and lockdowns (brooks et al., ; liu et al., ; mazza et al., ; mucci, mucci, & diolaiuti, ; pierce et al., ; vizard et al., ; wang et al., ) . international tourism is interrupted, and domestic tourism reemphasised, with surges in national park visitation. there are thus new opportunities for outdoor tourism enterprises demonstrating psychotherapeutic outcomes (buckley, ) . here, we showed that relatively low-key, localized outdoor tourism products can indeed improve the mental health of their clients. our data were compiled prior to the pandemic, but their importance has increased as a consequence of the pandemic. our approach adopts the recently proposed tourism-nature-health theoretical paradigm (buckley, (buckley, , buckley, zhong, & martin, ) . this paradigm argues that for the us$ billion p.a. parks and nature tourism sector (balmford et al., ) , mental health is an integral consideration across the entire sector. our findings here, from a commercial outdoor tourism clientele now representing % of the adult female population of australia, show that tourism can generate substantial and widespread psychotherapeutic benefits. these are novel findings, with considerably greater scale, scope, and generality than any previous analyses (buckley, ) . they provide large-scale empirical support for the tourism-nature-health paradigm. maintaining or improving mental health is a major motivation to visit parks and nature, and tourism provides the mechanism. this paradigm is broader than previous theoretical approaches to tourism and health, which framed wellness tourism as purchasable products or luxury goods (lengieza et al., ; smith & diekmann, ; vada et al., ) . it will influence how we analyse the motivations, expectations, experiences, satisfaction, and intentions of nature tourists; and the design, pricing and marketing of nature tourism products and destinations. its theoretical ramifications are thus widespread. our findings here confirm emotional, restorative, and worldview psychological outcomes (buckley, ; xie & fan, ) . they also demonstrate, for the first time, that commercial nature tourism can create therapeutic effects such as psychological rescue, recognition of previously missing life components, and flow-on to family members, which are key aims of clinical mental health treatments such as chemotherapies and counselling (bourdon, el-baalbaki, girard, lapointe-blackburn, & guay, ; lee, bullock, & hoy, ; mueser et al., ; swan, keen, reynolds, & onwumere, ) . the concept of emotional rescue is well established within popular culture (richards & jagger, ) , but using tourism to achieve it is a new addition to social practices (buckley et al., ) . the concept of a missing life component, revealed through outdoor tourism products based on walking in nature, is also novel. there is extensive research on what constitutes a full or meaningful life, in different cultures (hooker, masters, & park, ; steptoe & fancourt, ) . the perspective put forward here by individual participants, however, that their lives were unknowingly incomplete until nature was included, is novel. previous research on tourism and wellbeing has treated holidays as adding quantitatively to quality of life, but here we show that it can also add a qualitatively new life component, a more powerful finding. flow-on effects of improved mental health to other family members are also a novel finding. it has been well established that poor mental health in parents, both female and male, has flow-on consequences for children (bowlby, ; flouri & buchanan, ; lavenda & kestler-peleg, ; luebbe & bell, ; repetti, taylor, & seeman, ) , and that these may persist lifelong (fingerman, huo, graham, kim, & birditt, ; lee et al., ; mallers, charles, neupert, & almeida, ; stafford et al., ) . here we show that women's walking-in-nature tourism also yields benefits for partners and children. future research could therefore include interviews with all the family members concerned. outdoor tourism may also yield direct benefits for men's mental and social health, and for singles, grandparents and retirees, not included in the current study. results reported here reveal a much wider variety of mental health outcomes than previous analyses of outdoor recreation. some of the outcomes identified, such as transformation, gratitude, and clarity, whilst not reported previously for hiking, have been identified for highly active outdoor pursuits, including extreme sports (booth, ; buckley, a; collins & brymer, ; holmbom et al., ; houge mackenzie & brymer, ; morris & scott, ; roberts et al., ; zanon, curtis, lockstone-binney, & hall, ) . other outcomes identified here, such as happiness, relaxation and destressing, challenge, and companionship, have been reported in previous qualitative studies of hiking (davies, ; kelly et al., ; lyu et al., ; richardson & mcewan, ; wensley & slade, ) . results reported here are derived directly from real-life tour clients, not experimental subjects. except for recovery from stress, outcomes identified here are very different from those reported in previous experimental psychology research on nature exposure. parameters such as improved attention and cognition, and reduced use of antidepressants, were not mentioned at all by participants in the current study, in contrast to previous experimental approaches (biedenweg et al., ; bratman et al., ; buckley, brough, a , b clough et al., ; frühauf et al., ; frumkin et al., ; niedermeier et al., ; oh et al., ; seymour, ; shanahan et al., ; wang et al., ; white et al., white et al., , wyles et al., ) . qualitative methods, such as the netnography used here, routinely provide opportunities to extend the range of parameters considered. from an economic or health-services perspective, at least some of our participants had experienced severe mental and social health obstacles, which they overcame by taking part in outdoor tours, at no public cost, with no side effects, and with benefits lasting months, years or longer. worldwide, poor mental health is increasingly prevalent and costly (mcdaid et al., ; patel et al., ) . chemotherapies and counselling are focussed on clinical cases. therapeutic opportunities from outdoor tourism are thus globally significant for individual wellbeing and quality of life, and for the economics of national healthcare systems. participants in this study were drawn from one particular demographic and socioeconomic group, namely urban and suburban women with families, in a developed country. this group experiences differentially high levels of depression, and social and family barriers to outdoor adventure (buckley et al., ) . the tourism products analysed here provide them with accessible and affordable outdoor experiences, and a social atmosphere and sense of community amongst the regular clients. these yield mental health benefits that range from happiness and relaxation, to psychological transformation and rescue; and social health benefits derived from carryover to other family members, whether or not those other members took part themselves. these are significant and valuable outcomes. mental health is always important for everyone, and everyone's mental health is suffering during the covid- pandemic (liu et al., ; mazza et al., ; mucci et al., ; pierce et al., ; vizard et al., ; wang et al., ) ; but women's mental health is under particular threat from disproportionate loss of income and employment, family stresses, and domestic violence, with reduced options for escape (brooks et al., ; graham-harrison, giuffrida, smith, & ford, ). there will be strong demand for mental health rehabilitation during post-pandemic social and economic recovery. the role of outdoor nature-based tourism in women's mental health is thus particularly critical currently. this research showed that commercial outdoor tourism enterprises can contribute powerfully to the wellbeing of women and families. this provides empirical support for a new tourism-nature-health theoretical paradigm. three of the outcomes identified are entirely novel: psychological rescue, missing life-component, and family flow-on effects. we now need to test how these outcomes depend on details of tourism experiences and client circumstances; and compare 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constructions of femininity in the outdoors are some natural environments more psychologically beneficial than others? the importance of type and quality on connectedness to nature and psychological restoration tourist experience from an embodied perspective: grounded theory analysis of trekking journals and interviews examining future park recreation activities and barriers relative to societal trends how contact with nature affects children's biophilia, biophobia and conservation attitude in china ralf buckley is retired emeritus chair and president's international fellow, with a particular research interest in the psychological and conservation aspects of outdoor tourism founding director of wild women on top (www.wildwomenontop.com), and author of world class treks and natural exhilaration trek training®, wild women on top®, coastrek®. ethics protocol # / . key: cord- - ibo gn authors: Ćosić, krešimir; popović, siniša; Šarlija, marko; kesedžić, ivan; jovanovic, tanja title: artificial intelligence in prediction of mental health disorders induced by the covid- pandemic among health care workers date: - - journal: croat med j doi: . /cmj. . . sha: doc_id: cord_uid: ibo gn the coronavirus disease (covid- ) pandemic and its immediate aftermath present a serious threat to the mental health of health care workers (hcws), who may develop elevated rates of anxiety, depression, posttraumatic stress disorder, or even suicidal behaviors. therefore, the aim of this article is to address the problem of prevention of hcws’ mental health disorders by early prediction of individuals at a higher risk of later chronic mental health disorders due to high distress during the covid- pandemic. the article proposes a methodology for prediction of mental health disorders induced by the pandemic, which includes: phase ) objective assessment of the intensity of hcws’ stressor exposure, based on information retrieved from hospital archives and clinical records; phase ) subjective self-report assessment of stress during the covid- pandemic experienced by hcws and their relevant psychological traits; phase ) design and development of appropriate multimodal stimulation paradigms to optimally elicit specific neuro-physiological reactions; phase ) objective measurement and computation of relevant neuro-physiological predictor features based on hcws’ reactions; and phase ) statistical and machine learning analysis of highly heterogeneous data sets obtained in previous phases. the proposed methodology aims to expand traditionally used subjective self-report predictors of mental health disorders with more objective metrics, which is aligned with the recent literature related to predictive modeling based on artificial intelligence. this approach is generally applicable to all those exposed to high levels of stress during the covid- pandemic and might assist mental health practitioners to make diagnoses more quickly and accurately. the coronavirus disease (covid- ) pandemic and its immediate aftermath present a serious threat to the mental health of health care workers (hcws), who may develop elevated rates of anxiety, depression, posttraumatic stress disorder, or even suicidal behaviors. therefore, the aim of this article is to address the problem of prevention of hcws' mental health disorders by early prediction of individuals at a higher risk of later chronic mental health disorders due to high distress during the covid- pandemic. the article proposes a methodology for prediction of mental health disorders induced by the pandemic, which includes: phase ) objective assessment of the intensity of hcws' stressor exposure, based on information retrieved from hospital archives and clinical records; phase ) subjective self-report assessment of stress during the covid- pandemic experienced by hcws and their relevant psychological traits; phase ) design and development of appropriate multimodal stimulation paradigms to optimally elicit specific neuro-physiological reactions; phase ) objective measurement and computation of relevant neuro-physiological predictor features based on hcws' reactions; and phase ) statistical and machine learning analysis of highly heterogeneous data sets obtained in previous phases. the proposed methodology aims to expand traditionally used subjective self-report predictors of mental health disorders with more objective metrics, which is aligned with the recent literature related to predictive modeling based on artificial intelligence. this approach is generally applicable to all those exposed to high levels of stress during the covid- pandemic and might assist mental health practitioners to make diagnoses more quickly and accurately. the coronavirus disease (covid- ) pandemic and its immediate aftermath present a serious threat to the men-tal health of health care workers (hcws), who may develop elevated rates of anxiety, depression, posttraumatic stress disorder (ptsd), or even suicidal behaviors ( ). recent research related to the covid- pandemic ( , ) and middle east respiratory syndrome (mers) outbreak ( ) recognizes that hcws are at high risk for mental illness. therefore, urgent monitoring of their mental health is needed, particularly early prediction and proper treatments of nurses and physicians who were exposed to a high level of distress by working directly with ill or quarantined persons ( ). mental health risks of highly distressed individuals are further increased when they exhibit low overall stress resilience and have other vulnerability factors, such as the general propensity to psychological distress ( ) and low self-control ( ). recognition and identification of such individuals in early stages of acute stress is extremely important in order to prevent the development of more serious long-term mental health disorders, such as ptsd, depression, and suicidal behavior. however, mental disorders are difficult to diagnose, and even more difficult to predict due to the current lack of biomarkers ( ) and humans' subjectivity, as well as unique personalized characteristics of illness that may not be observable by mental health practitioners. currently, the diagnosis of mental health disorders is mainly based on the symptoms categorized according to the diagnostic and statistical manual of mental disorders (dsm- ) ( ). in such circumstances, one of the greatest impacts of digital psychiatry, particularly applied artificial intelligence (ai) and machine learning (ml) ( - ) during the ongoing covid- pandemic, is their ability of early detection and prediction of hcws' mental health deterioration, which can lead to chronic mental health disorders. further-more, ai-based psychiatry may help mental health practitioners redefine mental illnesses more objectively than is currently done by dsm- ( ) . regardless of the specific application, ie, prediction, prevention, or diagnosis, ai-based technologies in psychiatry rely on the identification of specific patterns within highly heterogeneous multimodal sets of data ( ). these big data sets may include various psychometric scales or mood rating scales, brain imaging data, genomics, blood biomarkers, data based on novel monitoring systems (eg, smartphones), data scraped from social media platforms ( ) , speech and language data, facial data, dynamics of the oculometric system, attention assessment based on eye-gaze data, as well as various features based on the analysis of peripheral physiological signals ( , ), eg, respiratory sinus arrhythmia, startle reactivity etc. such ai systems based on multimodal neuro-psycho-physiological features can detect mental health disorders early enough to prevent and reduce the emergence of severe mental illnesses and improve the overall mental health. therefore, ai has the transformational power to change a subjective diagnostic system in psychiatry to a more objective medical discipline. also, a new generation of ai in psychiatry might act as a self-explanatory digital assistant to psychiatrists. definitely, psychiatry today could benefit from ai's ability to analyze data and recognize patterns and hidden warning signs that a psychotherapist might miss. such timely information enables making diagnoses more quickly and accurately, and might be lifesaving particularly for all of those hcws who might have suicidal ideation ( , ) due to heavy mental distress during the covid- pandemic. hence, the aim of this article is to address the problem of prevention of hcws' mental health disorders by early prediction of individuals who may have a higher risk of later chronic mental health disorders due to high distress during the covid- pandemic. in order to reach this aim and enhance traditional subjective diagnostics and risk assessment approaches, the methodology proposed in this article is based on our extensive experimental research on the selection of resilient candidates for special forces during survival, evasion, resistance and escape (s.e.r.e.) training in collaboration with emory university school of medicine, atlanta, united states, and hadassah hebrew university hospital, jerusalem, israel ( ) . similar methodology has been applied in our project related to the selection of resilient candidates for air traffic controllers in cooperation with harvard medical school & massachusetts general hospital and croatia air traffic control ( , ) . these multi-year experimental research projects are based on a variety of questionnaires and experimental measurements, which include a set of comprehensive multimodal stimuli, corresponding multimodal neuro-physiological, oculometric and acoustic/speech responses, and complex feature computation. therefore, we do believe that future clinical research based on the proposed multimodal neuro-psycho-physiological features and ai analysis can detect mental health disorders early enough to prevent and reduce the emergence of severe mental illnesses. such reliable predictors of potential mental health disorders among hcws due to covid- stressors will be crucial for the mental health of hcws and maintaining high efficiency and productivity of medical institutions globally. the proposed methodology, described in figure and in the following phases, includes objective assessment of intensity of hcws' stressor exposure during the covid- pandemic described in phase , subjective assessment of stress experienced by hcws during the covid- pandemic based on the specific psychological questionnaire described in phase , distinctive stimulation paradigms designed and developed within phase , computed neuro-physiological features based on stimulation responses in phase , as well as statistical and ml data analysis described in phase . objective assessment of intensity of hcws' stressor exposure during the covid- pandemic is based on acquiring information from official hospital archives and clinical records regarding their daily schedules during the covid- pandemic, overtime work, the level of threat they experienced, sick leave, etc. these objective metrics of exposure to stressors are proposed based on analysis and adaptation of different questionnaires that have been used for assessment of stressors in military combat deployment and operation ( - ), as well as stressors in virus outbreaks ( ) ( ) ( ) ( ) . the key aim of this phase is to objectively stratify individual hcws according to the objective level of stress to which they were exposed during their clinical service, using the information provided by authorized clinical sources rather than by asking individuals to self-report themselves. phase : subjective stress assessment subjective assessment of stress experienced by hcws during their covid- pandemic clinical service is based on the questionnaire that is developed by a selection of the most appropriate items from general-purpose psychological questionnaires used for early recognition of distress, mental health disorder screening, and stress resilience (eg - ), as well as from specific covid- psychological questionnaires ( - , ). self-reported subjective peritraumatic reactions represent a valuable complement to objective dimensions of stressful situations collected in phase when trying to predict chronic mental health disorders, such as ptsd ( ) . accordingly, subjective self-reports of individual covid- stress intensity and relevant personality traits will also be used as one of the indicators of potential chronic mental health disorders in comparison with more objective metrics developed in phase . this phase is related to the design and development of appropriate multimodal stimulation paradigms in order to optimally elicit specific neuro-psycho-physiological individual reactions among hcw participants ( figure ). accordingly, the appropriate input-output multimodal experimental stimulation paradigms that elicit the specific multimodal features reflecting the impact of stress on the patients' neuro-psycho-physiological state ( ) are usually related to baseline neuro-physiological functioning; wellestablished generic stressful emotional stimuli, such as different versions of acoustic startle stimuli and airblasts; startle modulation paradigms, such as fear-potentiated and anxiety-potentiated startle ( ) , and prepulse inhi- ( ) , and are delivered binaurally through headphones. in order to induce laboratory fear, threat, or anxiety by means of predictable and unpredictable aversive events delivery ( ), other aversive stimuli can be used, eg, combinations of airblasts to the neck, aversive images on the screen and sounds ( ), as well as annoying but not painful electric shocks, eg, . - . ma, -ms duration. existing semantically and emotionally annotated stimuli databases can facilitate efficient and accurate search for optimal aversive audio-visual stimuli to include in the multimodal stimulation paradigms ( , ). cognitive tasks are usually administered through specifically designed programs that allow response duration and accuracy measurement. tion paradigms proposed in the previous phase and computation of corresponding features relevant for prediction of mental health disorders. the proposed methodology is based on state-of-the-art sensors for measurements of the individual's multimodal neuro-psycho-physiological reactions: functional near-infrared spectroscopy (fnirs); electroencephalography (eeg); peripheral physiology, ie, electrocardiography (ecg), electromyography (emg), electrodermal activity (eda), respiration; speech/acoustic and linguistic reactions; and facial/gesture and oculomotor reactions ( , ) . such measurements, obtained as a response to relevant stimuli described in phase , have the potential to objectivize traditional diagnostic methodology in psychiatry. in our laboratory, the biopac mp system (biopac systems inc., goleta, ca, usa) is used for the acquisition of the neuro-physiological signals. a gazepoint gp hd eye-tracker (gazepoint, vancouver, canada) is used for detection of spontaneous blinks, tracking of changes in pupil dilation, and gaze tracking. a microphone and a webcam are used for collecting speech and gesture data, while the fnirs biopac model imager together with the cobi studio software (biopac systems inc.) is used for brain activation measurements. after pre-processing of the neuro-physiological signals, ie, obtained inter-beat interval time-series based on the detected qrs complexes in the ecg signal, preprocessed respiratory and eda data, accordingly filtered emg data for eyeblink startle response assessment, an array of relevant multimodal features is computed ( , ) . these features are elicited and computed according to the relevant research findings related to their associations with specific positive or negative mental health disorder predictors or outcomes, such as stress resilience/vulnerability and other personality traits, distress, anxiety, ptsd, or depression. therefore, these features are defined and computed in a theory-driven manner. examples of such features are resting heart rate ( , ) and heart rate variability (hrv) ( , ) , respiratory sinus arrhythmia ( , ) , hrv-based psychophysiological allostasis ( , ) , emg-based and figure . design and development of multimodal stimulation paradigms for optimal elicitation of specific neuro-psycho-physiological individual reactions; adapted from ( ) . hcw -health care workers; fnirs -functional near-infrared spectroscopy; eeg -electroencephalography; ecg -electrocardiography, emg -electromyography; eda -electrodermal activity. the illustration was partially assembled from public domain/free sources: https://publicdomainvectors.org, http://www.stockunlimited.com, https://commons. wikimedia.org. eda-based startle reactivity ( ), various features related to speech prosody ( ), prefrontal cortex activation on various cognitive tasks ( , ) , and alpha band-related parietal eeg asymmetry ( ) . such integrated multimodal neuropsycho-physiological prediction of mental health disorders emphasizes the importance of combining different multimodal features in enhancing predictive power of the proposed approach, since any single feature in the assessment and prediction of mental health deterioration is a relatively weak discriminator. due to potentially large amounts of highly heterogeneous data, phase is accomplished using cloud storage and cloud computing resources, as shown in figure . statistical correlation-based analyses are expected to provide better insight into the neuro-physiological risk markers for the development of chronic stress-related mental health problems affected by the covid- pandemic. feature selection and classification based on ml, as opposed to statistical methods, would explore more complex interactions between various features in a highly nonlinear manner as-sociated with the inference of risk of hcw individuals for the development of chronic mental health problems. individuals exhibiting high risk of chronic stress-related mental health problems may urgently need as prevention effective and efficient treatments, using state-of-the-art tools and means of digital psychiatry, such as computerized cognitive behavioral therapy ( ) and telepsychiatry, which are efficiently applicable in the early stages of illness ( ) . a more detailed description of the proposed tools and means of statistical and ml analyses is given in the following section. a data-driven verification of various multimodal neuropsycho-physiological features extracted in phase can be obtained by the application of statistical analyses and ml techniques in relation to the objective stress intensity assessment from phase , as well as subjective self-report indicators of experienced stress and relevant psychological traits from phase . phase can provide valuable insight into neuro-psycho-physiological risk markers for the development of chronic stress-related mental/physical problems in the context of the covid- pandemic, figure . multimodal data acquisition and feature computation. illustrated is a subset of features: hr mean -mean heart rate; hr recovery -heart rate recovery; rsa -respiratory sinus arrhythmia; rmssd -root mean square of successive differences; eda as -eda-based startle response measure; emg as -emg-based startle response measure; f voice -voice fundamental frequency; rms voice -voice energy -root mean square; f - -voice formants; zcr -voice zero-crossing rate; pd -pupil dilation; spv -saccadic peak velocity; fnirs hbo -oxygenated hemoglobin. and increase the translational potential of such features. a similar data-mining-based approach has been previously used in the analysis of diagnostic data for differentiating ptsd patients from participants with psychiatric diagnoses other than ptsd ( ) . this work has demonstrated the applicability of ml for the analysis of ptsd, but only based on the data obtained from structured psychiatric interviews and psychiatric scales, which is analogous just to phase of the methodology proposed in this article. in terms of statistical analysis, various correlation analysis approaches can be employed. one example of such methodology is the canonical-correlation analysis (cca), a technique suitable for investigating the relationships between variables coming from distinct sets, eg, the relationship between variables obtained in phase and phase , or phase and phase . in doing so, the cca will provide interpretable linear combinations of variables from different sets that have a maximum correlation. in order to maximize the statistical power of conclusions, ie, to avoid the large statistical corrections due to conducting numerous exploratory tests for significance of correlation coefficients, several particularly well-founded hypotheses should be defined a priori, before the computation of the full correlation matrix. these hypotheses should be those with the most overwhelming evidence from the literature regarding expected pairwise associations between specific objective metrics of the stress intensity exposure, subjective self-report metrics of experienced stress and relevant psychological traits, as well as objectively measured/computed neuro-physiological features. a brief overview of neurophysiological features with the highest predictive potential according to the research references is given in the description of phase . additionally, a subset of the obtained data can be used to separate the participants according to specific group memberships, eg, high distress vs low distress. for example, a recent covid- -related research paper ( ) uses data analogous to our proposed phase and phase to define resilience in the face of exposure to a stressor of a given intensity. however, in that work all data were obtained via self-report, while we propose the integration of objectively assessed stressor severity (phase ) and self-report data (phase ) with the relevant neurophysiological features (phase and phase ). accordingly, various regression analyses or even between-group tests can be conducted. regarding the application of ml, both unsupervised and supervised learning approaches should be considered. unsupervised learning approaches, such as principal component analysis, factor analysis, or cluster analysis, do not require labeled data and can help reveal previously undetected patterns in heterogeneous sets of data, and help in the understanding of the relationships between objective stressor severity, self-report assessments, and neuropsycho-physiological characterization of the participant. for example, a non-classical unsupervised learning approach, based on a brain-inspired spiking neural network (snn) model trained using eeg data, has provided novel insights into the brain functioning in depression and the effects of mindfulness training on the brain connectivity ( ) . such novel unsupervised approaches, based on the spike-timing-dependent plasticity learning rules of the snn connectivity emerging from complex spatio-temporal brain data, like eeg and fnirs, which are considered in the proposed methodology, could help reveal and understand early patterns of mental health deterioration in hcws. when considering labeled data, the main aim of supervised ml, as opposed to statistical methods, is the maximization of classification/prediction accuracy, while sacrificing model explainability and rigorous statistical validation. accordingly, recent work highlights the need to establish an ml framework in psychiatry that nurtures trustworthiness, focusing on explainability, transparency, and generalizability of the obtained models ( ). this approach, regardless of the superior classification/prediction performance, is critical in order for the ai methods to be employed in diagnosis, monitoring, evaluation, and prognosis of mental illness. supervised learning in the context of the proposed methodology can be formulated both in terms of regression and classification tasks. neuro-physiological features obtained in phase can be integrated by a model, eg, support vector machine, random forest, artificial neural network, etc, in the accordingly formulated supervised learning task. for example, data from phase can be used to model various labels emerging from phases and , such as estimation of objective stressor severity, available from phase ; or classification of high vs low distress in hcws based on the data obtained in phase . to summarize, technology based on ai and ml can only be as strong as the data the models are trained on, which is particularly important in mental health diagnostics. currently, for most classification or prediction tasks emerging from the area of mental health, labels are most likely still not quantified well enough to successfully train an algorithm. one possible outcome regarding this labeling issue, as briefly stated in the introductory section, is in data-driven ai technologies helping mental health practitioners re-define mental illnesses more objectively than is currently done in the dsm- . ad-ditionally, ai can help personalize treatments based on the patient's unique characteristics. such unique characteristics are often very subtle and hardly observable by human mental health practitioners. for example, subtle shifts in speech tone or pace can be a sign of mania or depression, and such patterns can now be even more precisely detected by an aidriven system in comparison to humans. ai can exploit language and speech, among many other available modalities, as one of the critical pathways to detecting patient mental states, especially through mobile devices ( ) , which should also be regarded as highly important in the context of prediction of mental health disorders induced by the covid- pandemic. the proposed methodology for prediction of mental health disorders among hcws during the ongoing pandemic based on ai-aided data analysis is particularly important since they are a high-risk group for contracting the covid- disease ( ) and developing later stress-related symptoms. however, the methodology proposed in this article might be applied generally for all those who were exposed to higher levels of such risks during the covid- pandemic. the main objective of the proposed methodology is to expand subjective metrics as predictors of potential mental health disorders mainly specific for phase with more objective metrics derived in phases , , and . the use of neuro-physiological features is expected to provide additional information and increase reliability when identifying particularly at-high-risk individuals. such efforts are well aligned with the growing literature regarding the application of ai methods in prediction of chronic mental health disorders, which has been initially focused mainly on self-report predictor variables ( , , ) but has been subsequently extended to speech features ( ) and various biomarkers ( 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biological markers routinely collected from electronic medical records key: cord- -fzusgbww authors: newby, j.; o'moore, k.; tang, s.; christensen, h.; faasse, k. title: acute mental health responses during the covid- pandemic in australia date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: fzusgbww the acute and long-term mental health impacts of the covid- pandemic are unknown. the current study examined the acute mental health responses to the covid- pandemic in adult participants in australia, using an online survey administered during the peak of the outbreak in australia ( th march to th april ). self-report questionnaires examined covid- fears and behavioural responses to covid- , as well as the severity of psychological distress (depression, anxiety and stress), health anxiety, contamination fears, alcohol use, and physical activity. % of respondents reported that their mental health had worsened since the outbreak, one quarter ( . %) were very or extremely worried about contracting covid- , and half ( . %) were worried about family and friends contracting covid- . uncertainty, loneliness and financial worries ( %) were common. rates of elevated psychological distress were higher than expected, with %, %, and % of respondents reporting elevated depression, anxiety and stress levels respectively, and one in four reporting elevated health anxiety in the past week. participants with self-reported history of a mental health diagnosis had significantly higher distress, health anxiety, and covid- fears than those without a prior mental health diagnosis. demographic (e.g., non-binary or different gender identity; aboriginal and torres strait islander status), occupational (e.g., being a carer or stay at home parent), and psychological (e.g., perceived risk of contracting covid- ) factors were associated with distress. results revealed that precautionary behaviours (e.g., washing hands, using hand sanitiser, avoiding social events) were common, although in contrast to previous research, higher engagement in hygiene behaviours was associated with higher stress and anxiety levels. these results highlight the serious acute impact of covid- on the mental health of respondents, and the need for proactive, accessible digital mental health services to address these mental health needs, particularly for those most vulnerable, including people with prior history of mental health problems. longitudinal research is needed to explore long-term predictors of poor mental health from the covid- pandemic. levels in the current cohort. we also expected people with lived experience of prior mental health diagnoses would have higher rates of distress and would be vulnerable to poorer mental health during the current pandemic. finally, we predicted that engaging in precautionary hygiene behaviours would be associated with lower distress. status (including whether they had recently lost their job due to , the industry of their main job, and the frequency at which they had worked from home during the past week (not at all, a little, sometimes, most of the time, all of the time). participants were asked whether they had a chronic illness (yes, no, unsure, prefer not to say) , and completed a single-item measure assessing their self-rated heath (idler & benyamini, ) , with responses on a -point scale from poor to excellent. participants were asked whether they had ever been diagnosed with a mental health problem such as depression and anxiety (yes, no, unsure, prefer not to say) , and whether they were currently receiving treatment for a mental health problem including medications, counselling, or psychological therapy (yes, no, unsure, prefer not to say) . participants were asked to complete single item measures of i) how lonely they were feeling, ii) how worried they were about their financial situation, and iii) how uncertain they were feeling about the future, on a -point scale (not at all, a little, moderately, very, extremely). they were then asked to rate how the compulsion [ ] , and iv) a specific measure of behavioural responses to the pandemic based on our prior study [ ] , and past research investigating behavioural responses to pandemics [ , ] . finally, we assessed physical activity levels using the physical activity vital sign [ ] which assessed i) the number of days in the past week they engaged in moderate to strenuous activity, and ii) the average number of minutes they exercised at this level, and screened for hazardous alcohol use using the modified alcohol use disorders all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . identification test ] . all questionnaire responses were anchored to the past week, except for the audit-c (past month), and the padua contamination subscale (general). the mental health and lifestyle questionnaires were administered in randomised in order to minimise responding biases. participants were asked about their own covid- status (i have caught unsure, or other (open text) ). they also indicated whether they were in self isolation (yes -i am in voluntary self-isolation, yes -i am in forced self-isolation, no). participants were also asked i) whether any of their family or friends had contracted no, unsure), and ii) how concerned or worried they were that their friends or family members would contract covid- (not at all, a little concerned, moderately concerned, very concerned, extremely concerned). participants were asked five questions relating to their perceived risk from, and worry about, covid- . the first question assessed how concerned or worried respondents were about catching covid- on a -point scale (not at all concerned, a little concerned, moderately concerned, very concerned, extremely concerned). they then rated how likely they thought it was that they would catch the virus on a visual analogue scale (vas) from (not at all likely) to (extremely likely). they were asked how much they thought they could do personally to protect themselves from catching the virus (perceived behavioural control), on a (couldn't do anything) to (could do a lot) visual analogue scale. perceived illness severity was assessed by asking respondents how severe they thought their symptoms would be if they did catch covid- (response options were: no symptoms, mild symptoms, moderate symptoms, severe symptoms, severe symptoms requiring hospitalisation, and severe symptoms leading to death). finally, participants were asked about how much information they had seen, read or heard about coronavirus (nothing at all, a little, a moderate amount, a lot). all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . https://doi.org/ . to assess social distancing, hygiene and buying behaviours, participants were asked whether they had engaged in a total of behaviours during the previous week (see table demographic characteristics of the sample are depicted in table . overall, the sample was mostly female ( %), identified as being caucasian ( %), mainly spoke english at home ( %), and ranged in age from to over . participants were from various states and territories of australia, with the majority living in the most populated states of new south wales, victoria or queensland. sixty five percent were working in a paid job, and approximately one third were carers (for children, or people with a disability, illness, or the elderly). respondents' self-rated health was measured on a scale from poor ( ) to excellent ( ), with a mean of . (sd = . ). the majority of participants rated their health as 'fair' ( . %), 'good' ( . %), or 'very good' ( . %); relatively few participants rated their health as 'poor' ( . %)' or 'excellent' ( . %). only eight participants ( . %) reported that they themselves currently have or have had . % were unsure, and . % suspected they had covid- . approximately . % reported their family or friends had caught covid- , and . % were unsure. almost half ( . %) reported being in voluntary self- isolation, . % reported being in 'forced self-isolation' and . % were not self-isolating. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . level of concern and worry about the possibility of contracting covid- was moderate (m = . , sd = . , range - , where = not at all, = extremely concerned). a small proportion reported being 'not at all concerned' ( . %), % reported being 'a little' concerned, . % were 'moderately concerned ', . % were 'very concerned', and . % were 'extremely concerned' about contracting respondents' ratings of the perceived likelihood of contracting covid- was moderate (m = . , sd = . ; scale from to ). perceived behavioural control, or the belief that personal protective behaviours could help prevent infection, had a mean score of . (sd = . ). with regard to perceived severity of symptoms if they caught coronavirus, only . % of respondents indicated that they would experience no symptoms; with mild ( . %) and moderate ( . %) symptoms most commonly expected. however, one in three respondents perceived the illness severity to be high: with . % indicating they thought they would experience severe symptoms, severe symptoms requiring hospitalisation ( . %), or severe symptoms leading to death ( . %). in terms of the amount of information participants had been exposed to about the coronavirus in the past week, most participants ( %) reported having 'a lot' of exposure to information, . % reported a 'moderate amount', whereas very few reported a little ( . %) or no information at all ( . %). participants' overall level of concern and worry about friends and loved ones contracting covid- was moderate (m = . , sd = . , range - , where = not at all, = extremely concerned). a small proportion reported that they were 'not at all concerned' ( . %), . % reported being 'a little' concerned, . % were 'moderately concerned', . % were 'very concerned', and . % 'extremely concerned' about their friends or family members contracting covid- . the percentage of respondents who reported having engaged in a range of distancing and hygiene behaviours during the past week is presented in table . during the previous week, handwashing and social distancing (avoiding social events and gatherings) were the most common behaviours. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. note. numbers represent n and proportion (%) in brackets. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. more than three quarters of participants reported that their mental health had been worse since the outbreak, with . % selecting 'a little worse', and . % selecting 'a lot worse'. a small proportion reported improvements in their mental health since the outbreak ( . %) (see figure ) . a chi square analysis revealed that there was a significant difference in the impact of covid- on mental health for participants with and without a prior mental health diagnosis ( ( ) = . , p <. ), with . % of those with a prior mental health diagnosis saying their mental health had been 'a lot worse', relative to . % in the group without a mental health diagnosis. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. table shows the proportion of participants who scored across the severity categories of the dass- subscales. only . % of respondents scored in the normal range for depression, . % in the normal range for anxiety, and . % for stress. in contrast, . %, . %, and . % fell in the mild to moderate range for depression, anxiety, and stress respectively, whereas . %, . %, and . % reported severe or extremely severe stress levels. on the whiteley- , . % scored in the range indicating elevated health anxiety. of the participants who had valid scores on the physical activity vital sign (n= ), . % met national guidelines for minutes of moderate to vigorous physical activity in the past week. on the audit-c brief screener for alcohol use, approximately . % showed hazardous drinking levels. hazardous drinking levels were defined as an audit-c score of or more for women and other genders, and or more for men [ , ] . all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . comparison between people with and without prior mental health diagnosis people with and without a self-reported history of mental health diagnosis were compared in their severity of covid- fears, mental health, distress, health anxiety, alcohol use, contamination fears, and physical activity. people with a previous self-reported mental health diagnosis reported higher uncertainty, loneliness, financial worries, covid- fears (self and others), believed they were more likely to contract had lower perceived behavioural control, had higher rates of psychological distress, health anxiety and contamination fears, and lower physical activity than those without a self-reported mental health diagnosis history. there were no differences in alcohol use between these groups (see table ). was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. impact of self-isolation: compared to people who were not in self isolation, people who self-reported being in self-isolation reported higher uncertainty, loneliness, financial worries, and covid- fears (self and others), rated the symptoms of covid- as more serious, but believed they were less likely to contract covid- , and perceived more behavioural control over covid- . they also had higher rates of psychological distress, health anxiety and contamination fears, and lower alcohol use than those not in isolation. there were no differences in physical activity between these groups (see table ). was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . separate linear regression analyses were conducted to explore the demographic, occupational, and psychological predictors of dass- depression, anxiety and stress severity (see final model in table ). we entered demographic predictor variables (gender, age, occupational status, education, aboriginal and/or torres strait islander and carer status) in the first step. in the second step, we entered general health variables including chronic illness, mental health diagnosis history, and self-rated health. in the third step, we entered uncertainty about the future, loneliness, worry about finances. in the final step, we added covid- variables (whether they were in self-isolation, hygiene behaviours, exposure to covid- information, risk perceptions including perceived likelihood, perceived control, and severity of illness, concern/worry about contracting covid- , and concern/worry about loved ones contracting depression. demographic variables accounted for . % of the variance (r change = . , se= . , f change ( , ), = . , p <. ). entering the mental health diagnosis, chronic illness, and self-rated health variables accounted for . % of additional variance (r change = . , se= . , f change ( , ), = . , p <. ). in the third step, entering mental health variables accounted for . % unique variance (r all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . change = . , se= . , f change ( , ), = . , p <. ). finally, the covid- variables accounted for . % unique variance (r change = . , se= . , f change ( , ), = . , p <. ). the final model is presented in table and accounted for . % of the variance in depression scores. controlling for the other variables in the model, being female, more well educated, older, and having better self-rated health were all associated with lower depression, whereas being unemployed, a student, retired, carer or stay at home parent were associated with higher depression. mental health and chronic illness diagnoses were associated with higher depression, as were increased uncertainty about the future, loneliness, and financial worries. of the covid- variables, higher worry about covid- and perceived behavioural control over covid- infection were associated with lower depression, whereas perceiving higher illness severity was associated with higher depression. anxiety. in the first step, demographic variables accounted for . % of the variance in anxiety scores ( controlling for other variables in the model, being female, non-binary or different gender identity, and being aboriginal and/or torres strait islander were predictors of higher anxiety. older age, and more well educated (certificate, degree or higher) were predictors of lower anxiety. in contrast to depression, only being a student predicted worse anxiety. having a chronic illness, and prior history of mental health diagnosis were associated with higher anxiety, whereas better self-rated health was a predictor of lower anxiety. similar to depression, increased uncertainty about the future, loneliness, and financial worries were also associated with higher anxiety. of the covid- variables, more hygiene behaviours, worry about covid- , worry about loved ones contracting covid- , and higher perceived illness severity were all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . predictors of higher anxiety, whereas increased exposure to covid- information, and perceived control over stress. in the first step, demographic variables accounted for . % of the variance in anxiety scores (r change = . , se= . , f change ( , ) controlling for other variables in the model, identifying as non-binary or different gender identity, aboriginal and/or torres strait islander, predicted higher stress. being more well-educated with a trade certificate, and older age, were predictors of lower stress. being a stay at home parent was a predictor of higher stress. having a chronic illness, and prior history of mental health diagnosis were associated with higher stress, whereas better self-rated health was a predictor of lower stress. increased uncertainty about the future, loneliness, and financial worries were also associated with higher stress. of the covid- variables, more hygiene behaviours, worry about loved ones contracting covid- , and higher perceived likelihood of contacting covid were predictors of higher stress. higher perceived control over covid- predicted lower stress. all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . this survey presents the first insight into how the covid- pandemic has impacted the mental health of people living in australia, in a sample of individuals. rapidly disseminating an online survey enabled us to assess a large number of participants during the peak of the pandemic in australia to identify fears and acute distress and identify the relationship between demographic and psychological predictors of mental health. while very few individuals reported that they ( . %) or their family/friends ( . %) had contracted covid- , one quarter ( . %) of respondents were very or extremely worried about contracting covid- , and over half ( . %) were very or extremely worried about their family and friends contracting covid- . almost four in five participants reported that since the outbreak their mental health had worsened, with over half ( %) saying it had worsened a little, and almost a quarter of respondents ( %) saying it had worsened a lot. a small minority reported better mental health ( . %). results showed that many people are experiencing high levels of uncertainty about the future ( %), and half of respondents reporting moderate to extreme loneliness and worry about their financial situation. given loneliness, social isolation, and financial stress are significant risk factors for poor mental and physical health, and risk factors for suicidal ideation [e.g., , , ] , these findings are concerning. to rapidly respond to the evolving covid- situation, we administered online validated self-report questionnaires rather than diagnostic interviews. it is important to note that these questionnaires assessed symptoms of distress during the past week and should not be taken as indicative of a 'diagnosis' of a depressive or anxiety disorder. we found higher than expected levels of acute distress based on research in china during the covid- pandemic [ ] , and compared to normative data [ , ] . between . - . % of the current sample were experiencing severe or extremely severe levels of depression, anxiety and stress, and a further - % moderate symptoms. only % of the current sample had normal depression, % had normal anxiety, and % had normal stress levels, whereas in the chinese sample reported by wang et al. [ ] - % had normal anxiety, stress and depression on the dass- . these differences may be due to the high proportion of people with pre-existing mental health diagnoses ( %) in our sample, which have been shown to be a vulnerable group [ , ] , or because of the significant proportion with a self-reported chronic illness ( %), who may be more susceptible to more severe covid- disease, and therefore more all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . distressed. having a personal history of chronic illness was a consistent predictor of higher depression, anxiety and stress, whereas better self-rated health was associated with better mental health. compared to the australian population, this sample appeared to have poorer health, with % reported being in fair or poor health (compared to % in the australian population), and % reporting being in very good or excellent health (compared to % of australians) [ ] . our data gave some insights into other demographic variables which predict higher psychological distress. specific occupational factors predicted higher distress levels: student status (depression and anxiety), being an at home parent (depression and stress), a carer or retired (predicted higher depression), whereas education was associated with lower psychological distress. in contrast to past research, identifying as female predicted lower depression, however identifying as non-binary or a different gender identity was associated with higher self-reported anxiety and stress. identifying as aboriginal or torres strait islander also predicted worse anxiety and stress levels. these groups may be particularly vulnerable during the current pandemic, and longitudinal research is needed to explore the longer term predictors of poorer mental health over time. our results confirm fears about the potential impact of the covid- pandemic on people with lived experience of mental illness [ ] . participants with a self-reported history of mental health problems were more afraid of covid- and more worried about their loved ones contracting covid- , had higher distress, depression, anxiety, health anxiety and contamination fears, and higher rates of elevated health anxiety ( % versus %) than those without pre-existing mental health diagnoses. relative to those without mental health issues, a greater proportion of people with self-reported mental health problems had elevated health anxiety ( % versus %), and said their mental health had been 'a lot worse' since the outbreak ( % versus %). having a history of mental health issues was a consistent predictor of higher depression, anxiety and stress. because we did not collect any information about the history and nature of these mental health diagnoses, we cannot determine whether these individuals had higher distress prior to the pandemic, or whether distress increased as a result of the pandemic, due to inability to access usual supports, social isolation or loneliness [ ] . however, our findings highlight the need for proactive mental health all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . interventions for those who are experiencing elevated symptoms of depression, anxiety and stress during the current covid- pandemic, regardless of whether the distress is an exacerbation or recurrence of pre- existing mental health concerns, or new onset. digital interventions, which have been shown to be highly effective and cost-effective for depression and anxiety treatment [ ] will be crucial to respond to these ongoing mental health concerns, as they have capacity to deliver high quality interventions for distress at scale, and to those in social isolation who are unable to attend face-to-face services [ , ] . this study provides new knowledge about the rates of health anxiety during the covid- pandemic. over one in four ( %) of people with a prior history of mental health issues, and % of those without pre-existing mental health issues reported elevated health anxiety in the past week, which is higher than rates of health anxiety in the general australian population ( . % [ ]), and closer to the rates of health anxiety observed in general practice ( %) and outpatient medical clinic settings ( - %) [ ] . while these symptoms are not necessarily indicative of illness anxiety disorder, high health anxiety is likely to have significant ramifications for health service utilisation. responses to health anxiety vary substantially, with responses ranging from a complete avoidance of doctors, hospitals, and medical settings due to fear, to the other end of the spectrum of excessive, repeated, and unnecessary health service use, diagnostic testing, emergency visits and paramedic calls [ ] . proactive treatment of health anxiety with digital interventions may also be needed should these symptoms persist [ , ] . in prior research, risk perceptions, including the perceived risk of contracting the virus, perceived control over the virus, and the perceived seriousness of the symptoms have been shown to be associated with psychological distress, and behavioural responses to disease outbreaks. consistent with the findings of sars pandemics, and our previous study, we found moderate perceptions of risk of contracting the virus. participants rated on average that there was a % likelihood of contracting the virus personally, and higher perceived risk was associate with higher depression and stress levels. in the current cohort approximately one third of participants expected covid- to lead to severe symptoms ( . %), and in some cases death ( %), which is higher than in our previous study, where we found only % expected severe symptoms. the expected severity of the covid- illness differs markedly to the reality for most people, as studies show that % of people will experience no or mild symptoms [ ] . these findings reinforce the need for all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . education campaigns to address these misperceptions, especially as research has shown that these beliefs are associated with engagement with distress. these risk perceptions explained a relatively small amount of variance in the regression analyses, with perceived control over covid- a consistent predictor of better mental health and higher perceived severity of illness associated with higher depression and anxiety. however, it is important to note that other predictors, including loneliness, financial stress, uncertainty, demographic factors, and prior history of mental and chronic illness were stronger predictors of distress. similar to wang et al. [ ] , some of the most common precautionary behaviours were avoiding touching objects that had been touched by others, washing hands, and using hand sanitiser. participants also commonly reported staying at home and avoiding social events and socialising with others outside of the household. in contrast to media portrayals of panic buying, excessive purchasing behaviour was not common. in previous research, higher engagement in hygiene behaviours, such as handwashing have been associated with lower distress and anxiety, suggesting behavioural control may be protective for mental health. however, in the current cohort we found some inconsistent results, with engagement in more hygiene behaviours associated with higher anxiety and stress levels (they were not associated with depression). these findings differ to the findings of wang et al. [ ] during the early stages of the epidemic in china, where the use of precautionary measures, such as avoiding sharing utensils, hand hygiene and wearing masks were associated with lower stress, anxiety and depression. however, the current findings are consistent with some research from the sars epidemic, in which moderate levels of anxiety were associated with higher uptake of precautionary behaviours [ ] . it is possible that the association we found was due to people who were higher in anxiety or stress using these behaviours in an attempt to control anxiety. finally, concerns have been raised about the potential impact of social isolation and quarantine on physical inactivity, as well as increased alcohol use and abuse. on the audit-c brief screener for alcohol use, approximately . % met criteria for hazardous drinking levels, which is higher than the % found in primary care samples in australia [ ] and higher than usa-based population samples ( %- %) [ ] . however it is important to note that participants with a prior experience of mental health problems had lower rates of hazardous drinking, and lower rates of inactivity. in the current sample, . % met the all rights reserved. no reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which this version posted may , . . world health organisation. coronavirus disease (covid- ) situation report expected impact of covid- on the mental health of health professionals. a systematic review and meta-analysis of studies from the current and previous pandemics stress and psychological impact on sars patients during the outbreak. can j psychiatry psychological effects of the sars outbreak in hong kong on high-risk health care workers long-term psychiatric morbidities among sars survivors. general hospital psychiatry coping responses of emergency physicians and nurses to the 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practice? %j australian journal of primary health inconsistencies between alcohol screening results based on audit-c scores and reported drinking on the audit-c questions: prevalence in two us national samples chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-sars syndrome; a case-controlled study key: cord- -vl zhxyh authors: giallonardo, vincenzo; sampogna, gaia; del vecchio, valeria; luciano, mario; albert, umberto; carmassi, claudia; carrà, giuseppe; cirulli, francesca; dell’osso, bernardo; nanni, maria giulia; pompili, maurizio; sani, gabriele; tortorella, alfonso; volpe, umberto; fiorillo, andrea title: the impact of quarantine and physical distancing following covid- on mental health: study protocol of a multicentric italian population trial date: - - journal: front psychiatry doi: . /fpsyt. . sha: doc_id: cord_uid: vl zhxyh the covid- pandemic and its related containment measures—mainly physical distancing and isolation—are having detrimental consequences on the mental health of the general population worldwide. in particular, frustration, loneliness, and worries about the future are common reactions and represent well-known risk factors for several mental disorders, including anxiety, affective, and post-traumatic stress disorders. the vast majority of available studies have been conducted in china, where the pandemic started. italy has been severely hit by the pandemic, and the socio-cultural context is completely different from eastern countries. therefore, there is the need for methodologically rigorous studies aiming to evaluate the impact of covid- and quarantine measures on the mental health of the italian population. in fact, our results will help us to develop appropriate interventions for managing the psychosocial consequences of pandemic. the “covid-it-mental health trial” is a no-profit, not-funded, national, multicentric, cross-sectional population-based trial which has the following aims: a) to evaluate the impact of covid- pandemic and its containment measures on mental health of the italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. data will be collected through a web-platform using validated assessment tools. participants will be subdivided into four groups: a) group —covid- quarantine group. this group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with covid- + individuals; b) group —covid- + group, which includes isolated people directly/indirectly exposed to the virus; c) group —covid- healthcare staff group, which includes first- and second-line healthcare professionals; d) group —covid- mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. mental health services worldwide are not prepared yet to manage the short- and long-term consequences of the pandemic. it is necessary to have a clear picture of the impact that this new stressor will have on mental health and well-being in order to develop and disseminate appropriate interventions for the general population and for the other at-risk groups. the covid- pandemic and its related containment measures-mainly physical distancing and isolation-are having detrimental consequences on the mental health of the general population worldwide. in particular, frustration, loneliness, and worries about the future are common reactions and represent well-known risk factors for several mental disorders, including anxiety, affective, and post-traumatic stress disorders. the vast majority of available studies have been conducted in china, where the pandemic started. italy has been severely hit by the pandemic, and the socio-cultural context is completely different from eastern countries. therefore, there is the need for methodologically rigorous studies aiming to evaluate the impact of covid- and quarantine measures on the mental health of the italian population. in fact, our results will help us to develop appropriate interventions for managing the psychosocial consequences of pandemic. the "covid-it-mental health trial" is a no-profit, notfunded, national, multicentric, cross-sectional population-based trial which has the following aims: a) to evaluate the impact of covid- pandemic and its containment measures on mental health of the italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. data will be collected through a web-platform using validated assessment tools. participants will be subdivided into four groups: a) group -covid- quarantine group. this group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with covid- + individuals; b) group -covid- + group, which includes isolated people directly/indirectly exposed to the virus; c) group -covid- healthcare staff group, which includes firstand second-line healthcare professionals; d) group -covid- mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. mental health services worldwide are not prepared yet to manage the short-and long-term consequences of the pandemic. it is necessary to have a clear picture of the impact that this new stressor will have on mental health and well-being in order to develop and disseminate appropriate interventions for the general population and for the other at-risk groups. keywords: pandemic, global mental health, post-traumatic stress disorder, burn-out, anxiety, depression, resilience background the ongoing covid- pandemic represents an unprecedented event in terms of consequences for physical and mental health of individuals and for the society at large ( ) ( ) ( ) ( ) . in order to reduce the spread of the virus, national and international bodies and institutions have ordered quarantine, physical distancing, and isolation almost everywhere in the world. however, the psychological consequences of quarantine, such as frustration, loneliness, and worries about the future are well-known risk factors for several mental disorders, including anxiety, affective disorders, and psychoses ( ) ( ) ( ) . from a medical and sociological viewpoint, the pandemic caused by covid- represents a unique event, since it does not resemble any other previous traumatic event, such as earthquakes or tsunamis ( ) . in those cases, the traumatic factors are usually limited to a specific area and to a given time; affected people know that they can "escape" from the event. on the contrary, in the case of covid- pandemic, the "threat" can be everywhere and can be carried by every person next to us ( ) ( ) ( ) . therefore, people living in cities most severely impacted by the pandemic are experiencing extremely high levels of uncertainties, worries about the future and fear of being infected. the only comparable studies are those carried out during the sars outbreak ( ) ( ) ( ) ( ) ( ) . those studies showed that people experienced fear of falling sick or dying, feelings of helplessness, increased levels of self-blame, fear, and depression ( ) ( ) ( ) ( ) . during quarantine and physical distancing, internet and the social media can be useful in reducing isolation and increasing opportunities to keep in contact with family members, friends, and co-workers at any time ( , ) . however, internet may also represent a risk factor for mental disorders, in particular internet gaming disorder. moreover, internet can also have a negative impact on mental health of the most vulnerable people, such as those who live alone or the elderly, since it spreads an uncontrolled amount of information (a situation known as "infodemic"). in the current pandemic, the impact of quarantine and physical distancing on the mental health of the general population has been explored only in a few studies, mostly conducted in china, where the pandemic started ( ) ( ) ( ) . qiu et al. ( ) found that % of the population experienced psychological distress; in particular, those more vulnerable to stress and more likely to develop post-traumatic stress disorder were women and individuals aged between and years or older than years. moreover, people were more concerned about their own health and that of their family members, while less concerned about leisure activities and relationships with friends ( , ) . after china, italy has been the first country to face the contagion of covid- and one of the countries with the highest number of deaths due to this coronavirus (http://www. salute.gov.it/portale/nuovocoronavirus/). on march , the lockdown status has been declared by the italian government. this status included the definition of specific containment and quarantine measures, such as the interdiction of all public meetings and strict movement restrictions (i.e., possibility to go out only for working, serious health reasons, or other urgent needs). these containment measures have been prolonged until may . moreover, the expected psychosocial and emotional reactions to the pandemic observed in the general population may be significantly different in the chinese and italian populations due to their socio-cultural characteristics and historical contexts, which obviously impact on people's behaviors and attitudes. furthermore, the organization of public health system is different in italy compared to china and other eastern asian countries, also due to financial constraints. in fact, although in those countries the model of care has shifted in the last years to become more similar to a western model of care, it has to be acknowledged that years is a relatively short period of time, and differences may still persist. methodologically rigorous studies are needed in order to evaluate the impact of covid- and quarantine measures on the mental health of italian population. these data will help us to develop appropriate interventions for managing the psychosocial consequences of the pandemic ( ) ( ) ( ) . the present study has been developed with the aims to: a) evaluate the impact of covid- pandemic and its containment measures on mental health of the italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. the "covid-it-mental health trial" is a no-profit, not-funded, national, multicentric, cross-sectional population-based trial involving the following eleven sites: university of campania "luigi vanvitelli" (naples), università politecnica delle marche (ancona), università milano bicocca, università "statale" (milan), university of perugia, university of pisa, sapienza university of rome, "cattolica" university of rome, university of trieste, university of ferrara; the center for behavioral sciences and mental health of the istituto superiore di sanità (rome). the department of psychiatry of the university of campania "luigi vanvitelli" in naples is the coordinating center, which has originally conceived the study idea and design. an online survey has been set up through eusurvey, a web platform launched in by the european commission. the application, hosted at the department for digital services (dg digit) of the european commission, is available to all eu citizens at https://ec.europa.eu/eusurvey. the survey will be online from march to june , (https://ec.europa.eu/ eusurvey/runner/covidsurvey ). the survey takes approximately - min to be completed. participants can stop the survey at any time and save their answers as "draft" on the web-platform. furthermore, participants can interact with the principal investigator of the study and with all researchers through email messages at any time during and after study participation. participants will be subdivided into four groups: a) group -covid- quarantine group. this group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with covid- + individuals; b) group -covid- + group, which includes isolated people directly/indirectly exposed to the virus; c) group -covid- healthcare staff group, which includes firstand second-line healthcare professionals; d) group -covid- mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. the survey addresses the italian population aged over years through a multistep procedure: ) email invitation to health professionals and their patients; ) dissemination of the link through social media channels (facebook, twitter, instagram) and the mailing lists of national psychiatric associations; ) involvement of national associations of stakeholders (e.g., associations of users/carers); ) official communication channels (e.g., university websites; websites of the hospitals directly involved in the management of the pandemic). the invitation letter includes information on study purposes and confidentiality. the provision of the informed consent is mandatory in order to start the survey. the snowball sampling procedure-without the definition of strict inclusion/exclusion criteria (except that of age limit)-will give us the opportunity to recruit a large sample of the italian population and to evaluate the effect of the studied variables on the outcome measures. the survey includes the following self-reported questionnaires: the general health questionnaire - items (ghq- ) ( ); the depression, anxiety and stress scale - items (dass- ) ( ); the obsessive-compulsive inventory -revised (oci-r) ( ); the insomnia severity index ( ) ; the severity-of-acute-stress-symptoms-adult ( ); the suicidal ideation attributes scale (sidas) ( ); the impact of event scale - items ( ); the ucla loneliness scale -short version ( ) ; the brief cope ( ); the post traumatic growth inventory short form ( ) ; the connor-davidson resilience scaleshort form ( ) ; the multidimensional scale of perceived social support ( ); the pattern of care schedule (pcs)-modified version ( ); the maslach burnout inventory (only for health professionals) ( ) . respondents' main socio-demographic characteristics, as well as data on their internet use, will be collected through an ad hoc schedule. all assessment instruments used for the study are detailed in table . the primary outcome of the study is the global score at the dass- . this choice is due to the fact that this assessment measure has already been used in a large population study carried out in china, thus giving us the opportunity to compare the italian situation with the chinese one ( ) . our study hypothesis is that the pandemic and the related containment measures are associated with higher levels of depressive and anxiety symptoms in the surveyed population compared to a community italian sample not exposed to the pandemic ( ) . furthermore, a significant difference between groups will be identified (covid- quarantine group = covid- healthcare professional second-line < covid- + group = covid- healthcare professional first-line group < covid- mental health group). in the covid- quarantined group, the severity of obsessivecompulsive symptoms, evaluated through the oci-r, the perceived loneliness and suicidal ideation will be considered as secondary outcome measures. in the covid- + patient group, the severity of post-traumatic symptoms at the severity-of-acute-stress-symptoms-adult scale will be considered. the hypothesis is that post-traumatic symptoms are more severe in this group compared to the other ones. in the covid- health staff group, the presence of burn-out symptoms, in particular mental exhaustion, and suicidal ideation will be considered. we anticipate that first-line professionals will report higher levels of mental exhaustion and suicidal ideation compared to second-lines staff members. in the covid- mental health group, the secondary outcome measures will include the adoption of maladaptive coping strategies (e.g., drinking alcohol) and a poor resilience style. patients with pre-existing mental disorders are expected to adopt more maladaptive coping strategies and poorer resilience styles compared to the other three groups. the use of internet and social media will be tested as possible moderator of the impact of pandemic and quarantine ( figure ) . moreover, the exposure time to covid- and to the related containment measures will be tested as possible mediators of the severity of the clinical symptomatology. finally, the other exploratory outcomes will include the variety of coping strategies and resilience styles as well as the different levels of post-traumatic growth. statistical analyses will be conducted according to a multistep plan. missing data will be handled using the multiple imputation approach ( ) . descriptive statistics will be calculated for the dependent and confounding variables. a bilateral alpha of . is considered, and error and confidence intervals are calculated at %. the analytic plan will include: ) data cleaning of the online dataset and replacement of missing values; ) descriptive statistics of the general characteristics of the recruited sample, in terms of levels of depressive and anxiety symptoms, posttraumatic and stress-related symptoms, insomnia, satisfaction with life, suicidal ideation, hopelessness, post-traumatic growth, resilience, coping strategies, and social support; ) sub-groups analyses based on the level of exposure to the pandemic (i.e., covid- quarantine group vs. covid- + patients group vs. covid- healthcare staff group vs. covid- mental health group); ) calculation of a propensity score, in order to adjust our findings for the likelihood of being exposed to the pandemic and to the quarantine ( , ) . this method is adopted since it produces a better adjustment for differences at baseline, rather than simply including potential confounders in the multivariable models. the independent variables used for calculating the propensity score will include gender, age, socio-economic status, and geographical region. the obtained propensity score will be used to weight the observations in the multivariable analyses. in the final regression model, the inverse probability weights, based on the propensity score, will be applied in order to model for the independence between exposure to the pandemic/ quarantine and mental health outcomes and estimation of causal effects ( , ); ) development of a structural equation model (sem), in order to evaluate the possible role as mediators and moderators of coping strategies, post-traumatic growth and usage of social networks on the severity of depressive and anxiety symptoms, post-traumatic and stress-related symptoms, suicidal ideation, and hopelessness. in order to improve the external validity and generalizability of our findings, all analyses will be controlled for the impact of confounding variables, such as age, gender, and geographical region. data will be stored in an online dataset by the coordinating center. for safety reasons, the dataset will be protected by a twostep password. it will be possible to export data in compatible formats with common calculation software (e.g., microsoft access and excel) and in specific softwares (e.g., spss and stata) for the statistical analyses. this study is being conducted in accordance with globally accepted standards of good practice, in agreement with the declaration of helsinki and with local regulations. the study protocol has been approved by the ethical review board of the university of campania "l. vanvitelli" (protocol number: /i). our survey will give us the opportunity to describe the impact of the pandemic on the mental health of different subgroups of the italian population. in fact, the analyses will be run according to the four subgroups of respondents: the general population not directly affected by the virus (covid- quarantine group); people who have had a direct or indirect contact with the virus (covid- + patients group); those working in health care units as first or second-line staff (covid- healthcare staff group); people with mental health problems, independently from the contact with the virus (covid- mental health). this choice is due to the evidence that stress and traumas have a different impact on different target groups ( , ( ) ( ) ( ) . in the covid- -quarantine group, we anticipate that the pandemic and the related containment measures will increase the levels of stress, anxiety and depression, as well as other stress-related symptoms. in particular, physical distancing has obviously changed the patterns of daily routine in order to mitigate the spread of the disease, with serious consequences on mental health and well-being in both the short-and long-term ( ) . similar consequences would require immediate efforts for developing preventive strategies as well as direct interventions aiming to mitigate the impact of the outbreak on individual and population mental health. the longer the pandemic will last the most the ordinary life of the general population will be seriously affected. in particular, zhang et al. ( ) have highlighted the need to pay attention to the mental health of people who have not been directly infected by the virus though have been forced to stop all their activities during the outbreak. these people represent the most susceptible group to the detrimental impact of quarantine and physical distancing measures adopted during the lockdown. moreover, during the current pandemic, it is reasonable to expect that the incidence of severe mental disorders will increase, but also that of other mental health disturbances not reaching the threshold for a full-blown diagnosis ( ) . however, currently available data are based on studies carried out in china and the different socio-cultural context may limit the generalizability of findings to the italian and western contexts. therefore, we consider essential to collect italian data in order to develop data-driven guidelines for an adequate management of mental health problems during the emergency and the post-emergency phases. in fact, this survey will represent the starting point for developing, validating, and implementing psychosocial supportive interventions ( , ) , as discussed later in this paper. we hypothesized that internet and social media can play a buffering role in the development of psychiatric symptoms ( , ) . it may be that online contacts and interactions will limit the detrimental effects of social isolation ( ) . moreover, internet can represent the ideal setting for providing supportive interventions through tele-mental health applications ( - ). however, the positive effect of internet and social media has to be confirmed yet, since it is only speculative at this stage. in the covid- + patient group (i.e., those with a direct or indirect contagion), the impact on mental health has been mostly neglected during the acute emergency phase. of course, this has been due to the fact that the infection is a potentially lifethreatening condition, as confirmed by the need for hospitalization in intensive care units for many patients ( ) . in particular, the experience of being isolated in the hospital, the perceived danger, uncertainty about own physical conditions and the fear of dying alone can be considered risk factors for the development of post-traumatic, anxiety, and depressive symptoms ( , ) . the only study conducted in china so far has documented that over % of covid+ patients admitted to the hospital reported significant post-traumatic stress symptoms ( , , ) . furthermore, the authors found that providing patients with psychoeducational intervention is well received and perceived as helpful and useful by users. as regards the effects on mental health of those working in health care units as first-line or second-line staff (covid- healthcare staff group), we expect that many health professionals will experience symptoms of burn-out, including mental exhaustion, irritability, detachment from reality, and insomnia. in a survey involving medical and non-medical health workers, zhang et al. ( ) found a higher prevalence of insomnia, anxiety, depressive symptoms, somatization, and obsessive-compulsive symptoms in mental health staff. moreover, front-line medical staff working in close contact with infected patients (e.g., staff professionals working in the departments of respiratory, emergency, infectious disease, and intensive care unit) showed higher scores on depressive/anxiety symptoms and had a twofold increase in risk to develop a mental health problem ( ) ( ) ( ) ( ) . however, the effect on suicidal ideation of health professionals has not been investigated yet and will be the focus of one of our work-packages. finally, the pandemic will affect the mental health status of people who already suffer from mental health problems, independently from the contact with the virus (covid- mental health group). although the effects of the coronavirus on mental health have not been systematically studied, it is likely that the covid- will have detrimental effects on patients with pre-existing mental health problems. many patients with severe mental disorders have been overlooked during the pandemic, although they can have a higher risk of contracting the virus and of death considering the higher prevalence of somatic comorbidities compared to general population and the difficulties in accessing health services ( ) . however, if protracted, social isolation may increase the risk of recurrences of episodes of mental disorders, beyond triggering the onset of new mental disorders in most vulnerable people. moreover, objective social isolation and subjective feelings of loneliness are associated with a higher risk of suicidal ideation and suicide attempts ( ) . for many persons with mental disorders, being alone is a heavy burden, far beyond that experienced by many other persons ( ) . in patients with pre-existing anxiety disorders or obsessivecompulsive disorder, we expect an exacerbation or worsening of their clinical symptoms. moreover, the fact that there is not (yet) a definitive treatment for the covid infection represents another potential stressor, further increasing the levels of anticipatory anxiety and reducing personal functioning. in our study, both obsessive-compulsive and anxiety symptom clusters will be evaluated through reliable and validated questionnaires. we believe that our study has several strengths, which should be highlighted. first, this is the first national multicentric, noprofit study carried out in italy with a rigorous methodology for evaluating the impact of pandemic and quarantine on mental health. second, the development of a web-based platform for data collection will give us the opportunity to recruit a high number of participants. based on previous population surveys carried out in italy, an ideal target would have been , participants, but this target has been reached in only days. therefore, we expect to reach more than , people within the study period. a third relevant strength of our study is the selection of validated and reliable assessment instruments, which are available and validated in several languages. the next step of the project will be to adapt our survey to the european level, by involving several countries. fourth, several psychopathological dimensions will be evaluated, not only those usually assessed following natural disasters, such as the post-traumatic and depressive-anxious dimensions. in this study, we will also evaluate the obsessive-compulsive spectrum, the suicidal ideation, the maladaptive use of internet, among the others, which represent novel targets for psychiatrists ( , ) . our study has obviously also some limitations. in particular, the study sample includes the adult population only, due to existing restrictions related to the provision of informed consent of children and adolescents in italy. however, it is likely that the pandemic will have a detrimental impact on the mental health of adolescents as well ( , ) . moreover, being exposed to a traumatic event during early life is associated with alterations in the social, emotional, and cognitive development and could determine a variety of impairment in the adulthood. the effects of the pandemic on children and adolescents will be evaluated in an ad hoc study, in which we will explore the relationship between parents and their underage children during the pandemic. another limitation is related to the recruitment process, which might partially bias our findings, since only persons interested in the topic of the survey may have voluntarily participated. however, we expect that most people are interested in participating in the survey given the global magnitude of the current traumatic threat with collective psychological and social reactions. another possible limitation of our study is the choice to use a web-based online survey, which may have limited the participation of people not having access to the internet or not familiar with online tools, particularly the elderly. the cross-sectional design of the study does not allow an evaluation of changes over time as regards the levels of severity of symptoms. however, in order to overcome this possible bias, we will compare our findings with those already available from the italian population ( ) and will adopt a propensity score approach in order to understand the impact of the duration of exposure to the pandemic on the risk of developing psychiatric symptoms. with this methodology, we will be able to evaluate the levels of post-traumatic growth and the type of resilience styles in the study population in order to identify possible critical areas to be targeted in the post-acute phase. however, these psychological constructs are slow to change, and this is why we will promote a second wave of the survey, which will start six months after the end of the "lockdown phase" in italy. finally, the survey link can be used multiple times in order to allow sharing and re-posting it. this methodological choice could bias the findings, since the same person can potentially compile the survey several times. however, this methodological choice was due to the adoption of the "snowball" sampling, and it is rather unlikely that someone can compile the same long survey more than once. based on the findings of this study and on our previous work in the development of psychosocial interventions ( - ), we aim to develop a psychosocial intervention which will include elements of classic psychoeducation, cognitive-behavioral therapy, and motivational intervention ( ) ( ) ( ) ( ) ( ) . in particular, we are developing an experimental intervention which includes information on the mental health consequences of the pandemic and on strategies to prevent them; practical advices for promoting healthy lifestyle behaviors (e.g., healthy eating, regular sleeping patterns, physical activity, etc.); stress-management techniques; communication strategies; problem-solving skills. based on participants' needs, additional sessions on suicide prevention, burn-out, and internet dependence may be provided. the intervention will include face-to-face sessions and telemental health sessions ( , ) . information will be provided through instant messages (e.g., chatbot), email contacts, and the development of an ad hoc app. the modules of the intervention will be adapted according to the characteristics and the needs of the four above-mentioned target groups. in particular, in the covid- quarantine group, the main focus of the intervention will be the improvement of healthy lifestyle behaviors; for the covid- + patients group, the intervention will include a specific focus on post-traumatic symptoms and on the risk of being socially stigmatized; for the covid- healthcare staff group, specific sessions will be dedicated to the burn-out syndrome and the management of stressful situations; for the covid- mental health group, sessions on resilience, coping strategies, and the detection of early warning signs of relapses will be included. the proposed experimental intervention will be tested in a randomized controlled trial which will start when the acute phase of the pandemic will be over, and the control group will be represented by an informative group intervention on the effects of the pandemic on mental health. moreover, our survey is going to be translated into different languages in order to assess the impact of the pandemic in other european countries. the pandemic and the quarantine may have a detrimental impact on mental health. an increase of psychiatric symptoms and of mental health problems in the general population is expected. most health professionals working in isolation units and resuscitation departments very often do not receive any training or support for their mental health care. mental health services worldwide are not prepared to manage the short-and long-term consequences of pandemic. it is necessary to have a clear picture of the impact that these new stressors are having on mental health and well-being in order to develop and disseminate appropriate preventive interventions for the general population as well as for the different atrisk groups. this study is being conducted in accordance with globally accepted standards of good practice, in agreement with the declaration of helsinki and with local regulations. the study protocol has been approved by the ethical review board of the university of campania "l. vanvitelli" (protocol number: /i). vg, gais, ml, vv, and af designed the study and wrote the protocol. ua, gc, cc, fc, bdo, mn, mp, gabs, at, and uv revised the draft of the paper. all authors contributed to the article and approved the submitted version. we are very grateful to the healthcare professionals, patients, and general population who have dedicated their time to participate in our study. the consequences of the covid- pandemic on mental health and implications for clinical practice the psychological impact of 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study protocol psychoeducational intervention for perinatal depression: study protocol of a randomized controlled trial family management of schizophrenia: a controlled study of clinical, social, family and economic benefits a protection motivation theory of fear appeals and attitude change toward a theory of motivational interviewing scaling up psychological treatments for common mental disorders: a call to action hickie ib. the role of new technologies in monitoring the evolution of psychopathology and providing measurement-based care in young people the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. key: cord- -zefd yw authors: fang, min; hu, sydney x.; hall, brian j. title: a mental health workforce crisis in china: a pre-existing treatment gap coping with the covid- pandemic challanges date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: zefd yw nan on th apr , the chinese national bureau of statistics released news that china's economy shrank . % in the first quarter of compared to the previous year. this signals that thee road toward recovery will likely be long. risks to mental health come not only from the covid- pandemic (rajkumar, ) , but also the consequences of the economic downturn. unemployment and lost income can be expected among marganizalized and disadvantaged such as the migrant workers (liem, wang, wariyanti, laktin, & hall, ) . rural citizens are another significant group of vulnerable people. they have already lost income for months, in addition to losses to their initial agricultural investment, since roads were blocked causing no access to buy feed for their livestock. these groups of people are likely to encounter high level of psychological burden, as they may have less savings, let alone protection against financial catastrophe. loss of employment and financial stressors are wellrecognised risk factors for suicide (nordt, warnke & seifritz et al, ) . as the vicious circle of pychological distress and income inequality continues, online counseling services for people affected by the covid- crisis will be needed (dan, ) , but they may be far from sufficient (liem, sit, arjadi, patel, elhai, hall, ) . on top of the large pre-existing treatment gap, china might face a mental health workforce crisis. since , the chinese government began to prioritize mental health infrastructure development due to a high burden of mental disorders and gap in available services. a recent prevelance estimate of mental disorders in china was . % (huang, wang, wang, et al., ) . several steps were taken. firstly, the annual budget for all psychiatric hospitals rose from . million yuan ( . million usd) in to . million yuan( . million usd) in with an annual growth rate of %. secondly, china invested a large amount of funding to improve the basic construction and facilities of psychiatric hospitals. for example, since , the central government has directly invested . billion yuan (usd . billion), and the civil affairs department invested . billion yuan(usd . billion) aiming to build new or expand existing hospitals to achieve full coverage of mental health services in each prefecture-level city. consequently, from to , the total number of psychiatric beds in china increased rapidly from , to , , with an annual increase of . % and . beds per , people, which is above the world average (who, ) . the number of psychiatrists increased from , in to , in , at an annual rate of . %; however,the number of hospital beds per psychiatrist only increased from . in to . in . the workforce gap continues to grow, and investment into the mental health workforce has yet to catch up. below are some of the major reasons. . currently, there are about , new psychiatrists each year. however, less than half of this group receive formal psychiatric training; they receive only short-term psychiatric training before "transitioning" to psychiatric service work. there are , primary health care institutions in china, but few have access to psychiatrists. other types of professionals such as psychologists, social workers, and occupational therapists have not increased. china has roughly , clinical psychologists, compared to the united states, which has roughly , psychologists, for a population of one-quarter in size. also, only a small number of economically welldeveloped areas in china have social workers serving mental health patients. underlying this lack of mental health resources in primary care might be the predominance of a biomedical model of health. . the public funding mechanism is hospital-based. currently, the allocation of funding is based on the number of beds and the number of psychiatrists. under the double stimulus of fee for services payment and inadequate budget for hospitals, which only accounted for % of the total hospital revenue, most psychiatric hospitals have strong incentives to provide inpatient services for profit. in fact, in , % of psychiatric services were provided in hospitals. . effective monitoring and evaluation of the performance of mental health services have not been established. currently, the most important performance indicators are the overall cure rate and improvement rate of psychiatric inpatient care. these indicators ignore a large number of community patients who were discharged or those who are not yet screened and diagnosed. internationally, a range of comprehensive indicators are used to measure service performance, for example, suicide-related indicators during and after hospitalization, as well as mortality rates of patients with schizophrenia and bipolar disorder (oecd, ) . china has made progress mostly in the medical care of severe mental disorders in hospitals. common mental health conditions, including depression and anxiety, especially remain unaddressed. in china, like in most developing countries in the world, less than % of people with mental disorders sought advice or treatments (gbd, ) . low perceived need for treatment, lack of available treatments, and stigma are among barriers to care (shi, shen, wang, hall, ) . at the same time, few health professionals like nurses, social workers, and even doctors specialized in psychiatry, would like to specialize in mental health, partly due to lower status relative to other specialties (chen, conwell, cerulli , et al., ) and fear of medical violence (xiong, hu & hall, ; hall, xiong, chang , et al, ) . to reduce the burden of population' mental health caused by covid- and other disasters and emergencies, a large expansion of well-trained mental health providers is urgently needed. financial disclosure: none declarations of interest: none. primary care physicians' perceived barriers on the management of depression in china primary care settings china adopts non-contact free consultation to help the public cope with the psychological pressure caused by new coronavirus pneumonia asian journal of psychiatry global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries, - : a systematic analysis for the global burden of disease study prevalence of medical workplace violence and the shortage of secondary and tertiary interventions among healthcare workers in china prevalence of mental disorders in china: a cross-sectional epidemiological study the neglected health of international migrant workers in the covid- epidemic ethical standards for telemental health must be maintained during the covid- pandemic covid- and mental health: a review of the existing literature barriers to professional mental health help-seeking among chinese adults: a systematic review the covid- pandemic, personal reflections on editorial responsibility mental health atlas . world health organization violence against nurses in china undermines task shifting implementation the work described has not been published previously and is not under consideration for publication elsewhere. the publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in english or in any other language, including electronically without the written consent of the copyright-holder. to verify originality, the article may be checked by any originality detection service.j o u r n a l p r e -p r o o f key: cord- -ke iktly authors: chew, alton ming kai; ong, ryan; lei, hsien-hsien; rajendram, mallika; k v, grisan; verma, swapna k.; fung, daniel shuen sheng; leong, joseph jern-yi; gunasekeran, dinesh visva title: digital health solutions for mental health disorders during covid- date: - - journal: front psychiatry doi: . /fpsyt. . sha: doc_id: cord_uid: ke iktly nan the coronavirus disease (covid- ) pandemic has had an immense impact infecting million individuals and claiming , lives globally as of july ( ) . the rapid spread was largely enabled by the onset of the outbreak in wuhan city just prior to the lunar new year season, a peak period in travel to and from china ( ) . fortunately, many regions have controlled initial outbreaks and shared their experiences. these have been recently summarized by the world health organization (who), highlighting the importance of developing targeted responses and enhancing communication to address the pandemic's impact ( , ) . notably, emotionally driven sharing of misinformation has featured prominently in this crisis, fueling both confusion and irrational anxiety among the public ( , ) . termed an "infodemic", this has far-reaching consequences on population health with a direct impact on overloaded health systems and an indirect impact on mental health, resulting in paranoia and behavioral responses like stock-piling due to disproportionate fear ( ) . the impact of misinformation in the media on public emotion and fear has been illustrated with the middle-east respiratory syndrome (mers), whereby it led to a surge in fear and sustained economic consequences ( ) . the psychosocial impact of large-scale disasters and previous outbreaks have been described, including increased incidence of mental health disorders ( ) . similarly, covid- has had a twofold detrimental impact on the mental health of populations subject to the psychosocial consequences of the pandemic, including the incidence of new onset mental health disorders as well as deterioration in the condition of patients with existing mental health disorders ( , ) . this impact is on the rise given the protracted lock downs, social isolation, and concomitant occupational stressors in the context of the weakened global economy ( ) ( ) ( ) . these factors highlight the urgent need to scale-up and decentralize mental health services to attain a multiplier effect in the provision and accessibility of these services to combat the pandemic-driven surge in mental health disorders ( , ) . fortunately, several reports have demonstrated the effectiveness of digital health solutions for various applications, including addressing gaps in mental health services ( ) . these solutions include cloud-based big data systems, artificial intelligence (ai)based chatbots, online health communities (ohcs), and telehealth platforms. several have already been extensively applied for the pandemic's direct impact on health, such as big data systems and telehealth for remote consultations ( , ) . this review summarizes relevant applications of digital health that can help address the indirect impact of the pandemic on population mental health. cloud-based big data systems have been successfully applied in previous infectious disease outbreaks by aggregating data from numerous possible sources including weather surveillance systems ( ) , queries in online search engines ( ) , and even connected devices among the internet of things (iot) such as mobile phones and drones ( , ) . applications of these systems range from early detection of outbreaks to facilitating global digital epidemiology collaborations that address unresolved clinical uncertainties, such as ocular findings for early detection of latent tuberculosis ( , ) . successful applications include monitoring dengue outbreaks using data on mobility from mobile phones ( ) or queries in search engines such as baidu in china ( ) . evidence is emerging for the value of these platforms beyond retrospective or real-time surveillance applications, to prospective projections of disease trends and clinical need. in the context of the ongoing pandemic, several potential applications of these tools have emerged, such as predicting outbreaks of covid- based on historic travel data and public health capacity ( ) . also, cornelia betsch and the covid- snapshot monitoring (cosmo) group evaluated methods for surveillance of behavioral responses to the pandemic ( ). these applications enable evidence-based approaches to localize public health responses and monitor their effectiveness, in accordance with who recommendations ( ) . related applications for mental health include the prediction of disorders such as depression, stress and anxiety, using publicly available data from websites like twitter ( ) . these applications are gaining traction in academic consciousness as digital data becomes more ubiquitous, as exemplified by the development of recommendations for evidence-based research using tools like google search to predict mental disorders ( , ) . there are also validated individual-level applications of big data, such as the use of ecological momentary assessment (ema) from passive behavioral monitoring of mobile data, that have been used to detect and monitor severity for a spectrum of mood and behavioral disorders ( ) . this ushers in the possibility of precision digital mental health with tailored recommendations to the individual, as recently described for panic disorder ( ) . these methods can be leveraged for useful applications during lockdowns, such as early detection of mental health disease onset or progression. however, unresolved barriers to implementation include ethical and privacy issues of populationlevel monitoring such as with big data systems for contact tracing, that would similarly apply to systems for mental health surveillance ( ) . measures to facilitate implementation include the use of high quality input data and clinical validation using formal diagnostic criteria, robust methodology, and actionable outcomes ( ) . nonetheless, these systems can contribute to responses to the pandemic and address the needs of the vulnerable groups during the recurrent lockdowns in response to local outbreaks, such as potential victims of domestic violence ( ) . ai chatbots utilize pre-programmed content and decision-trees for automated conversations using techniques such as natural language processing (nlp). these are more interactive than static digital repositories leading to higher engagement for patients ( ) . preliminary reports of ai chatbots that have been developed for mental health include solutions providing counseling for well individuals to improve psychological wellbeing ( ) . others include ai chatbots such as wysa for digital mental well-being with demonstrated effectiveness in patients with depression ( ), and woebot for cognitive behavioral therapy (cbt) in young adults with depression/anxiety symptoms ( ) . these tools have potential applications in the current pandemic and beyond for preventive care and mental health promotion. they also function as contingency solutions to expand surge capacity in the event of overwhelming clinical need ( ) . however, their applications needs to be supervised given limited clinical validation with robust experimental design ( ) . other challenges clinical ai have also been described in various specialities, including practical, technical, and sociocultural barriers to implementation ( , ) . particularly given the conversational nature of chatbots and linguistic variations in different populations, acculturation is needed to facilitate the implementation of chatbots in new populations, as demonstrated with ai chatbots for health professional training to address colloquialisms such as "singlish" in singapore ( ) . this is crucial to ensure emotional support or triage advice are perceived accurately by patients, and piloting messages will help ascertain effectiveness ( ) . validated community mental health assessment tools could be incorporated in future conversational ai chatbots to prompt regular self-reporting by patients of wellness and social inclusion for active population monitoring. these include the various iterations of the social and communities opportunities profile (scope) scale validated in the united kingdom and hong kong, as well as the mini-scope in singapore ( ) . applying ai chatbots in this manner using a "sorting conveyor" operational model could be transformative, whereby the ai solutions built with predefined criteria can re-direct individuals requiring more comprehensive psychological support to appropriate services within a stepped-care mental health service ( ) . open digital patient engagement platforms that allow any visitor to a website or application to view interactions between patients and/or healthcare providers are called online health communities (ohcs). ohcs could be the silver bullet to the "infodemic", which is largely attributed to the unfettered spread of viral misinformation in unverified sources or platforms like social media, crowding out official communication ( , ) . in the earlier example of the impact of misinformation on fear during mers, choi et al. found that it created a positive feedback loop leading to a spiral of growing misinformation and paranoia, with the publication of more inaccurate information by the media in a bid to capitalize on public interest ( ) . big data systems such as the aforementioned cosmo for behavioral surveillance provide measures of these phenomena to develop targeted public health communication messages-an essential first step to combat this problem ( ) . however, due to the speed of misinformation propagated online, there is increasingly a need to implement a digital effector arm for our monitoring systems ( ), one that amplifies reputable sources to directly combat misinformation in a transparent, scalable manner by addressing myths and promoting reputable sources of information ( ) . in singapore, such a solution was developed by askdr through needs-finding surveys and ideation with frontline providers (figure ). it combines network effects of social media with behavioral gamification to give registered medical professionals digital tools to crowd-source a coherent counter-narrative to misinformation ( ) . public health agencies should similarly develop or adopt such tools for the "last mile" of public health communication. in the context of the ongoing pandemic, key applications include promoting reliable information and directly breaking the "spiral of misinformation". direct potential applications of ohcs for patients at-risk of mental health disorders include lowering the barrier to access care and support for stigmatized illnesses such as anxiety and depression, by allowing patients to seek initial medical advice anonymously ( ) . apart from the provision of basic demographic information such as gender and age that are required to contextualize medical advice; otherwise, anonymous engagement also helps to address limitations such as privacy issues similar to those with big data systems ( ) . other applications of ohcs that can enhance public health responses to the pandemic include provision of triage advice to optimize right-siting of patients and reduce unnecessary healthcare presentations where appropriate. this "tele-support" can be used long-term for fundamental illness-related concerns that may not require formal consultation, such as questions about potential interactions of chronic medications with overthe-counter (otc) medications or other health products ( ) . finally, they provide an avenue for asynchronous patient engagement between outpatient appointments while protecting the privacy of healthcare providers, creating opportunities for patient support and early identification of at-risk individuals needing to be re-directed to formal mental health services online or in-person ( ). digital telehealth services have numerous embodiments including video-conferencing, store-and-forward technology, remote tele-monitoring with connected devices, and mobile health applications, all of which are increasingly applied in large-scale disasters ( ) . these can be used for either asynchronous or synchronous consultations with private discussions between patients and healthcare providers ( ) . existing descriptions of tele-mental health services indicate the importance of human support and interaction regardless of the embodiment of telehealth used ( , ) . although its application in covid- for mental health services has been greatly enabled by legislative changes ( ), the barriers to telehealth adoption that have kept it from becoming mainstream to date still remain ( ) . ensuring successful, sustained adoption requires active alignment with clinical needs when deploying services ( ) . nonetheless, tele-mental health services are critical to maintain the continuity of care for patients with mental health disorders by providing avenues for remote review and prescription re-fills ( ) . other avenues with long-term value to health systems include co-ordinated avenues for health professionals to engage patients with mental health disorders more frequently, facilitate early detection of those at-risk of selfharm, and enable preventive interventions such as motivational interviewing that reduce hospitalizations ( , , ) . apart from the traditional two-way teleconsultation between doctor and patient, multi-way conferencing or tele-collaboration by allied professionals remotely supported by clinicians has been described ( ) and is mainstreamed in countries like singapore to project tertiary care to nursing homes and intermediate and long-term care (iltc) facilities. covid- is the first "viral" pandemic that threatens to overwhelm mental health services in coming months as a result of fear perpetuated by misinformation alongside social isolation during lockdowns ( , ) these unprecedented challenges highlight the need to develop creative solutions to address the impending surge in mental health disorders ( , ) . the four technologies discussed in this review are potential avenues to expand the capacity and penetration of existing mental health services to address this indirect health impact of the pandemic. hybrid strategies combing various solutions in an overarching "pyramid" operational model may be required to rapidly scale-up stepped mental health services. this was illustrated in the saved study operationalizing telehealth for complexed emergency services ( ) . digital operationalization of mental health services can be similarly achieved using combinations of digital tools in comprehensive services such as illness management and recovery (imr) programs ( ) . imrs are structured mental health services incorporating multi-modal mental health interventions to promote self-management and optimize treatment. pioneered in america, they were externally validated and demonstrated to reduce readmissions and the post-illness recovery period of asian patients after discharge from in-patient psychiatric services ( ) . the pyramid base catering to the needs of the general population could include screening tools such as big data systems and/or ohcs to actively identify and/or engage at-risk individuals without pre-existing mental health disorders, as well as provide tele-support services to reduce risk of progression in patients with mental health disorders ( ) . as countries re-open, at-risk individuals can be directed to ai-based chatbots providing automated support as well as triage in a "sorting conveyor" operational model to further escalate care as appropriate to inperson or telehealth mental health services based on patient risk profile ( , ) . these requires modifications to traditional practice as described for telehealth cognitive processing therapy (cpt) services to treat post-traumatic stress disorder (ptsd), a condition likely to increase in coming months even among healthcare professionals due to the prolonged stress of frontline services or rationalizing care in some regions ( , ) . ultimately, the effective deployment of digital mental health services is greatly dependant on successful assimilation within existing health systems. patient willingness to use, provider acceptance, and even the quality of digital and hardware infrastructure are fundamental considerations that need to be addressed. this has been recently illustrated based on the challenges of implementing ai solutions for ophthalmology despite maturity of the technology ( , ) . deployment of digital health thereby needs to be driven by the needs of the target patient population, clinical acceptance, and validated effective applications ( ) . these considerations dictate the likely effective form of deployment for these digital tools. designing effective digital mental health care requires taking into account the wide range of patient needs determined by the severity of mental health disorder(s), social determinants of health (sdh), access to technology, and cultural acceptance, among others ( , ) . there is no "one size fits all" solution, and research in telehealth has demonstrated that individualized design considerations are critical to maximize acceptance, ensure effectiveness, and sustain adoption with recurrent use ( ) . meeting the needs of patients in a timely and cost-effective manner ensures sustained adoption beyond the covid- crisis. for provider adoption, stakeholder engagement methods have been advocated to map out clinical processes, participants, and individual responsibilities to actively plan deployment for telehealth ( ) and are just as important for other forms of digital health ( ) . firstly, this requires detailed mapping of the needs, roles, and incentives of stakeholders such as healthcare workers, logistic procurement teams, and chief medical informatics officers. they are prioritized into primary and secondary stakeholders based on their capacity to make or influence decisions about adoption of digital tools. subsequently, a deployment strategy is developed to maximize stakeholder alignment while minimizing disruption to existing processes or new responsibilities that may overburden stakeholders. this also yields crucial insights for communication strategies to engage individual stakeholder groups effectively. participatory approaches like these with design-thinking have been used to operationalize tele-health in complexed emergency services ( ), as well as develop solutions with targeted applications such as ai chatbots for automated adolescent mental health coaching ( ) . in tandem, it is important to address the needs of vulnerable populations that may fail to seek care, such as potential domestic violence or child abuse victims ( ) . they may require tailored solutions such as targeted deployment of mobile mental health services provided by allied mental health professionals that could be remotely advised by psychiatrists using "hub-and-spoke" telehealth to project services into these pockets of society. in conclusion, the massive health impact of the first "viral" pandemic has been fueled by global travel, social isolation, rampant misinformation in social media, and other intricacies of modern life. however, digital mental health tools are the silver lining we are fortunate to have, as they can empower responses to the covid- outbreak at a scale that was never before possible in human history. responding effectively to the mounting impact of this pandemic on population mental health may ultimately require us to leverage these digital health solutions to expand the capacity of mental health services and supplement face-to-face care with an intentional approach for successful deployment ( , ) . authors ac and ro are medical students on clinical research attachment with author dg. author h-hl is an adjunct associate professor at the saw swee hock school of public health (sshsph), nus, and concurrently chief executive officer, the american chamber of commerce in singapore. author rm is a tutor in academic english at the center for english language communication (celc), nus. author gk is a senior operational manager at the institute of mental health (imh), singapore. authors sv, df, and jj-yl are senior consultant psychiatrists at imh, singapore. author sv is also a professor at duke-nus, singapore. the author df is also the chairman medical board at imh, singapore, as well as president of the international association of child and adolescent psychiatry. df is concurrently adjunct associate professor at all three medical schools in singapore, nus, duke-nus, and lkc. dg is a senior lecturer and faculty advisor (medical innovation) at the national university of singapore (nus), and physician leader (telemedicine) at raffles medical group. authors ac, ro, and dg conceptualized the manuscript, researched its contents, wrote the manuscript, and edited all revisions. authors h-hl, rm, gk, sv, df, and jj-yl intellectually contributed to the development and writing of the manuscript, added text, and edited all revisions. coronavirus disease (covid- ) situation reports the sars, mers and novel coronavirus (covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? covid- : what is next for public health? covid- : mental health 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doc_id: cord_uid: qh efs the coronavirus covid- and the global pandemic has already had a substantial disruptive impact on society, posing major challenges to the provision of mental health services in a time of crisis, and carrying the spectre of an increased burden to mental health, both in terms of existing psychiatric disorder, and emerging psychological distress from the pandemic. in this paper we provide a framework for understanding the key challenges for psychologically informed mental health care during and beyond the pandemic. we identify three groups that can benefit from psychological approaches to mental health, and/or interventions relating to covid- . these are (i) healthcare workers engaged in frontline response to the pandemic and their patients; (ii) individuals who will experience the emergence of new mental health distress as a function of being diagnosed with covid- , or losing family and loved ones to the illness, or the psychological effects of prolonged social distancing; and (iii) individuals with existing mental health conditions who are either diagnosed with covid- or whose experience of social distancing exacerbates existing vulnerabilities. drawing on existing literature and our own experience of adapting treatments to the crisis we suggest a number of salient points to consider in identifying risks and offering support to all three groups. we also offer a number of practical and technical considerations for working psychotherapeutically with existing patients where covid- restrictions have forced a move to online or technologically mediated delivery of psychological interventions. the coronavirus (covid- ) is a newly emergent infectious disease caused by the novel severe acute respiratory syndrome coronavirus (sars-cov- ) virus, originated in december from mainland china, with initial cases emerging from the city of wuhan, hubei province (cdcp ; li et al. ) . although most individuals diagnosed with covid- present with mild to moderate respiratory symptoms, a substantially minority present with severe symptomatology, with accompanying need for hospital treatment, a further proportion needing intensive care unit (icu) admission, and an elevated fatality rate. risk of mortality follows a clear age gradient (verity et al. ). on th january , world health organization (who) officially declared the covid- epidemic as a public health emergency of international concern, followed by designation as a pandemic on th march (i.e., presence of illness across multiple continents). the rapid spread of covid- places huge strain on capacity, responsiveness and resilience of public and private healthcare systems worldwide (emanuel et al. ; legido-quigley et al. ) . across multiple countries this has been accompanied by implementation of public health policies significantly altering everyday life, such as the quarantine of citizens for significant periods of time, with both short-and longer-term consequences for psychological distress and wellbeing . at time of writing, the worldwide cases of covid- are steadily increasing across all continents. on th april , the cumulative total of individuals presenting with confirmed covid- was , , people, with a total of , deaths (who ). in many countries testing is limited to hospitalised cases, therefore these numbers are likely to significantly underestimate the true prevalence of covid- in the population, given they do not cover mild presentation and asymptomatic cases. there is emerging evidence of the psychological impact of covid- on populations, both directly due to the distress accompanying confirmed cases in individuals and their loved ones, and indirectly due to population health interventions such as quarantine. however, it should be emphasized that the majority of people are not expected to suffer from mental disorders emerging from the pandemic and its impact (taylor ). however, a significant percentage will experience intense emotional adjustment reactions, including fear of contagion (zhou ) , impact of prolonged quarantine xiao ) , the death of relatives , or increased social adversity as a consequence of geopolitical instability to civil society associated with the economic crisis (silva et al. ) . in china, a survey of people found that . % assessed the psychological impact of the situation as moderate-severe, . % reported moderate to severe depressive symptoms, . % moderate to severe anxiety symptoms, and . % moderate to severe stress levels. most respondents ( . %) spent between and h a day confined at home and the main concern ( . %) was that his/her relatives would become infected with covid- . based on our survey of preliminary current research and on previous literature on coping with past coronavirus-based epidemics (e.g. severe acute respiratory syndrome, sars; and middle east respiratory syndrome, mers) we identify three groups at risk for psychological morbidity during and after the covid- pandemic. the first group are healthcare professionals, particularly those working in inpatient physical health settings, who experience higher frequency of exposure to the virus and higher viral load in the workplace; compounded by significantly increased workload, high risk procedures and the low availability of necessary personal protective equipment (ppe). thus, health professionals are at risk of elevated levels of depression, anxiety and sleep disorders , and many among them harbour fears of being infected during work shifts. recent findings on medical students in the current crisis supporting this (al-rabiaah et al. ) . this is also in line with previous experiences from sars/ mers, showing frontline health professionals constitute a unique risk group, especially after pandemic containment ends and systems move towards mitigation of the disease impact (gardner and moallef ; lee et al. ) . of note, many other workers are exposed to the same risk and fear of contagion, such as police officer, postal carrier, emergency medical technicians or trash collectors. the second elevated risk group that should be considered include individuals who, as a result of the crisis, have been exposed to potentially traumatic events such as loss of a loved one, threats to one's health and to the ability to work and make a living, and concerns about their future capacity to maintain a sufficient income. these people may express symptoms of post-traumatic stress disorder (ptsd), depression or complicated grief disorder, consistent with the literature on psychological and psychiatric sequelae of global emergencies or disasters (goldmann and galea ) . this group may not emerge immediately within the pandemic, and presentations may only become apparent after several months, even after the incidence of covid- has peaked. a third group of people at increased risk for psychological problems consists of people with pre-existing psychopathology, especially those with severe or complex psychiatric disorders. their existing presentation may be exacerbated by extreme isolation due to exposure to either the virus or associated social distancing. in this sense, social distancing may exacerbate existing social isolation in this vulnerable group. there is conflicting evidence from previous studies on the responses of people with severe psychiatric disorders to different types of disasters such as earthquakes, with some evidence for higher levels of avoidance-related coping being associated with higher distress (horan et al. ), but other studies showing that this risk is somewhat disorder specific with pre-disaster mood and anxiety disorders, but not psychotic disorders, predicting further psychological distress (katz et al. ) . this group also includes individuals with more common psychopathologies (e.g. depression and anxiety) who were receiving primary care mental, health treatment or psychotherapy prior to the onset of covid- restrictions. other people exposed to psychological suffering are those who have to live alone during the quarantine, who has been recently bereaved by the coronavirus, but the bereavement process has been disrupted by the lockdown, and ones that are not allowed to visit their loved ones who are in hospital for whatsoever medical conditions. as duan and zhu ( ) highlight, specialized psychological intervention for covid- should be dynamic and flexible enough to adapt quickly to the different phases of the pandemic. in the early stages, clinical psychologists, psychotherapist and psychological intervention specialists should actively collaborate with the rest of the multi-professional healthcare system in the treatment of the immediate impacts of covid- presentations (mohammed et al. ) . this may take the shape of organising or enabling healthcare systems to orientate towards psychological impacts of a pandemic, facilitate public mental health approaches to increasing population awareness of mental health; or organizing systems for psychologically informed interventions. this may also include task-shifting of psychological interventions either to delivery through digital means, or by different professional groups. potential therapeutic targets include: . training and support for health professionals at 'high exposure risk' to identify and manage emotional reactions, that may hinder their clinical work in frontline health delivery. this includes, for instance, managing anxiety, fear of contagion, episodes of acute stress or promoting self-care/reducing burnout. the main objective of this approach is to maximise psychological resilience in as many professionals as possible who have frontline duties during a pandemic (chen et al. ). importantly, in the peak of a pandemic, interventions such as psychological debriefing, critical incident stress debriefing or any other single session intervention mandating staff to talk about their thoughts or feelings are not recommended. that said, compassionate and sensitive awareness of the impact of critical care on health care professionals can be used to facilitate one on one support, should that person wish it (nice ). . next it is important to engage emotionally vulnerable groups, especially people with previous psychopathology. the main goal here is to support individuals undergoing covid- treatment or preventative quarantine. the mental health symptoms of this group of patients with covid- should also be monitored, although the presence of non-essential professionals such as psychiatrists, clinical psychologists or social mental health workers in isolation rooms for covid- patients is completely discouraged. therefore, front-line psychological support either needs to be facilitated by medical staff involved in immediate care (which may not be possible if the health system is at capacity) or be implemented indirectly through telecare systems. serious psychiatric emergencies such as aggression, self-harm or suicide attempts will still need to be addressed in person. for patients with acute symptomatology and diagnosed or suspected covid- , professionals who assist them face-to-face should be protected to minimize the risk of contagion (e.g. via appropriate ppe) and ensure both their safety and that of the patient. all other outpatient psychological interventions can be effectively carried out by digital care. phone and internet enabled psychological interventions have been demonstrated to be clinically effective in a wide variety of mental disorders (irvine et al. ). related to this, it is also important to tailor standard mental health delivery for individuals with pre-existing psychiatric disorders to acknowledge the impact of social isolation and distancing on mental health as part of adaptation to 'life under lockdown' or quarantine. . relatives of patients admitted by the coronavirus in a severe condition, poorly prognosed or who have already died. in such interventions it is essential not to pathologize the normal emotional reactions of family members and it is important to establish clear and consensual criteria with all the professionals involved to determine whether intervention is more beneficial than not to do so (von blanckenburg and leppin ). as the pandemic plateaus, and societies begin to emerge from distancing, mental health symptoms such as hypochondriasis, anxiety, insomnia or acute stress, as well as symptoms consistent with ptsd are expected to present across health systems. in these cases, the first-line intervention should be psychological, minimizing as far as possible the use of drugs (nice (nice , . furthermore, the literature emphasizes the importance of not starting formal psychological treatments quickly and without careful assessment, including active monitoring. as noted above, although well intentioned, intervening in individual's natural coping mechanisms too early can be detrimental. there is evidence that these interventions may be ineffective or even increase the likelihood of developing ptsd (nice ) . special attention should also be paid to: potential for "re-traumatization" of ptsd presentations where trauma-focused therapies are implemented without adequate psychotherapeutic frameworks and structures (duckworth and follette ) ; and guarding against the development of interventions for those that have recovered from covid- that stigmatize or block access of the to a new functional identity as survivors of the pandemic (muldoon et al. ) . going forward it is also crucial to ensure individuals affected by covid- retain a sense of their overall identity, and that this is not subsumed into an explanatory model reduced to the illness. any intervention should be based on a thorough assessment of possible risk factors that may maintain the problem, the patient's prior state of mental health, the history of bereavement, the presence of a history of self-harm or suicidal behaviours in both the patient and his/her family, the history of previous traumas, and the socio-economic context of the patient. at this stage, it is also important to recognise the likely profound impact of covid- on economic, social, and political levels at all levels from the individual to international. this may, therefore, require mental health systems to adopt new ways of working with structural inequalities emerging from the aftermath of covid- and consistent with a social determinants of mental health model (e.g., lund et al. ). in organizing psychological assistance within and across various stages of the pandemic, we highlight four major challenges: . healthcare system deficits, both in terms of material and human resources (i.e., lack of adequate ppe, infrastructure for digital interventions, staffing) or in mental health professionals not specialized in the psychological approach of crises and emergencies (shultz et al. ; shultz and neria ) . in china, the scarcity of human resources led to individual professionals accumulating multiple responsibilities, reducing the effectiveness of their interventions (duan and zhu ) . for this reason, government, policy makers and health managers need to be aware of health systems strengthening for increasing the capacity of mental health professionals, facilitate training for emergency intervention, and monitor workload burdens, especially when sustained over time. . societal underestimation of the (short-and long-term) psychological consequences of pandemics and, consequently, limited resources to cope with them (bitanihirwe ). there is evidence that individuals exposed to public health emergencies have increased psychopathological vulnerability both during and after the potentially traumatic event (fan et al. ) . although the international covid- pandemic response has been unprecedented in terms of mobilisation of resource and finance, there will also be long-term impacts in terms of treatment burden, including mental health, particularly in low resource and conflict settings (un ). in china, the progression of covid- aggravated the mental health of infected patients, the general population and health professionals (duan and zhu ). therefore, it is important to evaluate and identify all risk groups and adapt interventions to their specific needs. among the variables to consider are disease trajectory, severity of clinical symptoms, place of treatment (inhome or out-of-home isolation, icu, etc.), history of previous trauma and, previous history of mental health problems. having this information will help classify people at risk and enable specific preventive mental health measures to be put in place. . poor planning and coordination of psychological interventions, especially when they are applied at different levels and by different professionals (zhang et al. ). in china, at the start of the covid- outbreak, the absence of adequate planning of psychological interventions led to fragmented or disorganized implementation, compromising effectiveness and efficacy, and hampering access to available health resources. any psychological intervention should be planned and coordinated together with all the social-health stakeholders involved, particularly primary healthcare services and specialized mental health services. this maximised the potential for adequate continuity of care even after acute phase of the pandemic recedes. . finally, there is also a risk attached to early crisis responses, leading to a proliferation of interventions and frameworks associated with an oversupply of well-intentioned but potentially non-evidence based, psychological assistance, often non-governmental organizations (ngo) and the third sector. this is not to say all ngo interventions are compromised, and indeed prevention in mental health is highly desirable. that said, delivery of preventive interventions must be balanced by delivery and/or supervision applied by appropriately qualified professionals (loewenstein ; ogden ). as previously noted, where health systems have sufficient flexibility, for those with existing mental health conditions should continue their psychological interventions by technology enabled means. this can include telephone consults, or increasingly via digital platforms such as skype, zoom or health provider developed platforms. this presents a number of specific challenges including familiarity with the technology (both therapist and client), adaptation of the therapeutic intervention, awareness of the additional parameters of delivering therapy in lockdown conditions, and the accompanying question of the purpose of therapy in such unusual circumstances. there are thus several difficulties that psychotherapists and practitioners have in adjusting their practice to technology enhanced therapy, which is now delivered from their own homes, as opposed to familiar public facilities or private practices. the following suggestions of how to adapt psychotherapy to this unique condition have emerged from our everyday clinical experiences over the adaptation to lockdown in several countries, and represent an attempt to systemize clinical practice for the duration of the emergence and of social life restrictions. therefore, we provide a number of key points to guide clinicians in adapting practice. -draft a new contract. many patients will have difficulties in accepting digital psychotherapy. clinicians must be clear that this is pragmatically the only option available (if this is the case), but also acknowledge and selfregulate their own difficulties with changes such as worry for the client's mental health, irritation with the option of discontinuing face to face psychotherapy or guilt at the idea of not being available enough. in all of these cases the clinician remains open for phone/video contact where the patient experiences psychological problem, but negotiation is required over whether sessions are for crisis-management only; or whether regular sessions are still possible and/or desirable to both parties. this can help retain a balance between acceptance of difficulties and the maintenance of a robust treatment framework. -raise the bar for what we consider psychopathology. reactions of distress, such as fear, rage, anxiety, obsessions, guilt, constriction, rebellion against authority, emotion and behavioural dysregulation, albeit transitory, are to a certain extent normal during a crisis. the clinician must first and foremost help the patients understand that their suffering is human and mostly unavoidable, this is not to say that they should be ignored or minimised. when patients can note how their mind is overwhelmed by symptoms, affect or relational problems, this creates a basis for agreement to work on them. -common factors (e.g., norcross and lambert ) are even more important than usual. in particular, we think that validation, sharing and self-disclosure become of uttermost importance. validation follows from the above, that adjustment to the 'new normal' is normal and patients experience is human. therapists can note how experiencing fears for their own and their loved ones health is understandable, that to be worried about the future of the economy is reasonable, how to behave with a certain degree of obsessions is adaptive (e.g. hand hygiene) or that unexpected losses of temper are to be expected in confinement. where sharing is appropriate, the clinician may provide examples of witnessing the same experiences and noting this is part of what the humanity is experiencing now. this is aimed at reducing feelings of self-shaming, self-criticism stigma, or guilt for one's own weaknesses. self-disclosure is unique in this aspect. above all, it is one of the most powerful interventions (safran and muran ) and in this moment becomes even more necessary. therapists may need to strategically disclose moments of their own personal vulnerability during the outbreak. we contend that in this moment clinicians should mindfully and tactically not stick to one of the principles of good self-disclosures (e.g., dimaggio et al. ) , that is clinicians should disclose well-regulated feelings and thoughts. in this moment, still having command over their own experi-ences, clinicians may disclose moments in which they experienced momentarily feelings of fear, even moving closer to panic, worry, anger, sadness, rebellion and irritation than one ordinarily would. this helps create a sense of human connection and reduces in session risk, on the client's side of self-blaming or setting unrealistic standards of good mental health for the self (safran and muran ; inchausti et al. ). this can be balanced in session with learning from these experiences of momentary dysregulation. -create the therapeutic environment. we are not working in our offices but often from our homes. the therapy space must be therefore be created anew. for video-therapy the clinician should choose what part of their home they want to show beyond their shoulders and possibly consider the patients' personality. equally, the therapists will be projecting a sense of their own identify in these choices. with some patients it is better to choose a more neutral/professional background, for example bookshelves or a working table. with other patients there is less this need, and they experience a sense of familiarity even when they see the kitchen of the windows of the therapists' home. in any case, asking patients for feedback about how they experience the therapist in this new environment is crucial. another issue is how to present oneself in the camera. absence of embodied intersubjectivity deprives the session of face-to-face aspects of the human connection. we consider that adjusting zoom of the webcam, which means placing oneself at some distance can be helpful. showing only one's face is artificial and deprives the client of gestures and nonverbal markers from the therapist. conversely, at least a halflength shot (e.g. breaking news conductors) is better and some background must be present, so the patients retains a sense of a human being in context. this way therapists can use arms and hands and chest and shoulders to convey nonverbal signals making communication more natural. alternatively, some patients may feel more comfortable without using a camera and the use of audio might suit them better. coping with such anxiety disorders as social anxiety might lead patients to avoid video. as in any form of coping, if using video is too much of an emotional burden to that client, the clinician accepts phone consultation, but keeps exploring the possibility to switch to video, which would be a kind of behavioural exposure. a compromise would be using a web platform with video disabled. simply accepting coping deprives the clinician the possibility to counteract psychopathology. whereas, gently asking if the patient feels ready to switch to video, and explore the cognitive-affective antecedents of the possible refusal gives precious information about residual maladaptive interpersonal schemas which are one fundamental therapy target. -help patients build their own environment. clinicians may offer suggestions for how to create a therapeutic space, safe and protected from interference. of course, having a private, distraction-free room is best, but even in this case patients can be suggested to use headphones and a microphone, and maybe some background music, so reducing the risk others listen. alternatively, sessions can be conducted over smartphone in the open, for example a private garden, the parking lot or one's car. trivial as they may sound, we have found these suggestions help many patients to accept and practice therapy even after initial reluctance. -therapeutic focus -only self-regulation and overcoming distress or exploration of opportunities for building healthy parts and pursuing autonomy, exploration and expanding the healthy self (dimaggio et al. ) . we have noted that in majority of cases where we have adjusted delivery of psychotherapy to fit the pandemic restrictions, patients are seeking a balance between acceptance of the current condition, whilst still trying to challenge maladaptive schemas and develop an emergent healthy part of the self. indeed, once issues relating to the present crisis have been dealt with, patient and therapist may explore how the current distressing conditions create suffering not only for their direct traumatic effects, but also because they may indirectly bring existing personality, cognitive and emotional vulnerabilities to the fore. thus, clinicians may help the patients connect their present experiences to lifelong vulnerabilities, enabling therapeutic work to continue as they did before the emergency, albeit with specific adaptations. for example, prior to lockdown patients with avoidant personality disorders may have started questioning schemas of themselves as inferior and others are judging and therefore, they coped with social avoidance (inchausti et al. ) . in this moment behavioural experiments aimed at increasing social contact and thus further challenging the schemas are more difficult to enact. yet, the clinician may still explore opportunities, and build more basic steps for future real-life exposures. patients looking for employment may be able to access online courses or training for life after. patients searching for romantic partner may use dating apps or explore the feelings and thoughts they experience when chatting with some new acquaintance. even the home may be a test ground for new experiments. one client related difficulty in showing personal vulnerabilities to significant persons because she had learned that if she revealed these emotions others either became unavailable or distressed; therefore, she had avoided disclosure, or felt guilty for burdening them. lockdown and having to live with her partner : helped her realize that there was no point in her concealing her personal feelings, thus she burst into tears with her partner; relating afterwards in therapy that she felt relieved as she realized that that was possible. this enabled schema-driven difficulties in continuing with disclosure of feelings could be addressed as a current therapeutic issue. finally, some practices like two-chairs, sensorimotor work, guided imagery exercises, can regularly be performed simply adjusting the zoom in the patient room. the therapists may ask the client to step back so the whole body can be observed and then ask to close their eyes and engage in guided imagery, or use bodily oriented work like grounding (lowen ) to enhance self-regulation or connecting with feelings of strength and personal agency. that said, for some patients that are unwilling or do not want to use this platform for treatment. if they are content to postpone specific elements of treatment until restrictions are lifted, the therapist should be sensitive in recognizing distress but also respecting the decision-making process. it is still possible to remain open to the patient recontacting the therapist to recommence therapy. to conclude, the covid- pandemic and associated disruption to society poses major challenges to the provision of mental health services. these challenges include the need to identify and monitor possible risk groups for psychological morbidity as well as exploring new ways of providing services. as a heuristic, it is useful to consider three (potentially overlapping) groups that can benefit from psychological frameworks for mental health, and/or treatment approaches. these are (i) healthcare workers engaged in frontline response to the pandemic and their patients; (ii) individuals who will experience the emergence of new mental health distress as a function of being diagnosed with covid- , or losing family and loved ones to the illness, or the psychological effects of prolonged social distancing; and (iii) individuals with existing mental health conditions who are either diagnosed with covid- or whose experience of social distancing exacerbates existing vulnerabilities. there are yet limited data on the mental health impacts of the current crisis, but evidence from past epidemics (e.g., mers and sars) offer a basis for identifying risk groups and preparing management strategies. the current crisis is the first global crisis in the age of mass internet supported communication, and this offers opportunities and challenges for delivering high-quality psychological therapies online. practical and technical adjustments to therapy can and have already been made, but as the pandemic unfolds it will be important to generate a corpus of knowledge both on the effectiveness of technologically supported psychotherapy, and to share technique in working with patients in an environment where technological changes intersect with societal changes due to the pandemic. middle east respiratory syndrome-corona virus (mers-cov) associated stress among medical students at a university teaching hospital in 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lessons from ebola. the lancet anxiety disorders. quality standard. retrieved march , , from www.nice.org.uk/guida nce/qs . national institute for health and care excellence (nice) psychotherapy relationships that workevidence-based therapist contributions do no harm: balancing the costs and benefits of patient outcomes in health psychology research and practice negotiating the therapeutic alliance: a relational treatment guide the ebola outbreak and mental health: current status and recommended response trauma signature analysis impact of economic crises on mental health care: a systematic review the psychology of pandemics. preparing of the next global outbreak of infectious disease covid- global humanitarian response plan estimates of the severity of covid- disease psychological interventions in palliative care immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china coronavirus disease (covid- ) technical guidance: infection prevention and control/ wash a novel approach of consultation on novel coronavirus (covid- )-related psychological and mental problems: structured letter therapy recommended psychological crisis intervention response to the novel coronavirus pneumonia outbreak in china: a model of west china hospital psychological crisis interventions in sichuan province during the novel coronavirus outbreak publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest we have no conflicts of interest to disclose. key: cord- - gq wy authors: tracy, derek k.; tarn, mark; eldridge, rod; cooke, joanne; calder, james d.f.; greenberg, neil title: what should be done to support the mental health of healthcare staff treating covid- patients? date: - - journal: the british journal of psychiatry : the journal of mental science doi: . /bjp. . sha: doc_id: cord_uid: gq wy there is an urgent need to provide evidence-based well-being and mental health support for front-line clinical staff managing the covid- pandemic who are at risk of moral injury and mental illness. we describe the evidence base for a tiered model of care, and practical steps on its implementation. the covid- pandemic is unprecedented in modern times. healthcare systems are struggling to manage clinical need, with concerns about the availability of adequate personal protective equipment (ppe) and covid- testing. staff, particularly those from black, asian and minority ethnic (bame) groups, will worry about their own greater risk of infection and that they might subsequently infect their loved ones. furthermore, healthcare staff are affected by wider societal and economic tensions, including the impacts of social distancing and fewer social resources. this complex combination of pressures risks adverse mental health outcomes. an emerging issue is how best to protect the well-being and mental health of staff contending with these circumstances. many are working outside of their area of expertise and training, with rapidly changing clinical guidelines, limited equipment and structural resources; greater numbers of significantly unwell patients, many of whom will die; and less-than-ideal staffing levels, in part owing to staff sickness and quarantining. the particular challenges of working in unprecedented ways that test their professional codes of conduct may, if sustained for a long enough period, induce what is known as 'moral injury'. all employers have a legal duty of care and moral obligation to provide appropriate support to their employees, including mitigating and responding to work-related traumatic incidents. not paying due attention to this risks poor performance, mental ill health and staff absences. however, we have precedent and learning from both past pandemics and dealing with the impact of traumatic events. this editorial describes the evidence base for optimising staff support and how healthcare systems such as the national health service (nhs) can practically implement such approaches. from 'moral injury' to evidence-based interventions the construct of 'moral injury', which is derived from military settings, is described when facing overwhelming demands for which one feels unprepared and where actions or inactions challenge an ethical code. it is associated with negative emotions such as shame or guilt, and can lead to the development of mental illnesses such as depression and post-traumatic stress disorder (ptsd). whether moral injury is of itself a subset of ptsd remains an area of debate and contention. however, conversely, most individuals exposed to trauma do not have long-term sequelae, even without support, and post-traumatic growth may occur in such settings. treating covid- is a risk for moral injury. professional codes teach us to provide care only when we feel adequately trained, experienced and equipped to do so. many healthcare staff may perceive that they are insufficiently prepared or equipped for their work during the pandemic. whether individuals experience injury or growth will be influenced by support received during and after this time. although not directly causative of moral injury, institutions and services have key roles in mitigating against the likelihood of adverse outcomes. however, to date there have been no explicit evidence-based practical plans published to guide staff and service providers. a tiered approach to anticipating, recognising and managing moral injury or mental illness should be taken. notably, emerging research shows that moral injury leads to mental disorders, including ptsd and depression as well as suicidality, in a minority. this approach includes: primary preventioninterventions to avert mental illness onset; secondary preventionfocusing on those with early signs of possible illness; and tertiary preventiontreatment of those with such problems. staff must be inducted with clear realistic information, frank briefings and reflection on the risks and challenges they face, includ- ing moral injury. this should subsequently be repeated at appropriate points such as the beginning or end of shifts. obvious covid- examples include wearing ppe for protracted periods, having many unwell patients in very acute settings and high mortality rates. a range of factors increase the risk for subsequent development of ptsd, including pre-disaster life events and mental illness, direct traumatic exposure, having tasks outside one's normal remit, and perceived risk to self or those with whom one lives. initial selfassessment declaration forms can help individuals consider these challenges and associated stresses and confirm their perceived suitability for such work. however, there is little evidence that prescreening staff has any predictive value. accurate, up-to-date information on available resourcesfrom self-help techniques, through to digital apps and online resourcesshould be clearly available on trusted and easily accessible locations such as organisational websites and posters. social support within teams should be fostered, potentially assisted by 'buddying up' shift-colleagues to monitor each other's well-being. beginnings and ends of shifts provide natural opportunities for team discussions and reviews to enhance camaraderie and foster team spirit. however, there is a lack of evidence for psychological debriefing and post-incident counselling, which may actually increase harms. these are not the same as leader-led operational debriefing, an important aspect of good leadership. team managers may benefit from active listening skills and trauma awareness training on, for example, actively making contact with those who seem to be avoiding discussions or meetings or are displaying evidence of 'presenteeism'. this can cover helping staff with problem-solving and facilitating access to professional support. fast feedback and improvement cycles should be established to learn from front-line staff. the work environment should be optimised to support appropriate nutrition, rest and sleep periods. there are numerous 'well-being' initiatives, in various formats, both covid- specific and more general. some are national, for example in the uk resources collated by the covid trauma response working group (www. traumagroup.org) and the royal college of psychiatrists (https:// www.rcpsych.ac.uk/about-us/responding-to-covid- /respondingto-covid- -guidance-for-clinicians). many specific well-being offerings lack evidence with regard to preventing the development of ptsd and these should be recommended with caution. staff with pre-existing mental health conditions might experience recurrence or deterioration; others will have de novo presentations. it is reasonable to assume that anxiety, depression, adjustment disorders, ptsd and substance use disorders will be the most commonly seen. although there is no evidence to support more generalised post-incident organisational screening, experienced welfare-focused staff with training in predisposing risk factors and developing signs of mental illness can be utilised to help identify individuals appearing to be developing difficulties and to appropriately follow them up, for example at the end of a shift. outcomes here might include no further input, signposting to well-being resources, or further assessment via general practitioner, occupational health or mental health services. evidenced peer-support protocols are available to train staff to look after each other. a notable example is the trauma risk management (trim) programme first developed in the uk armed forces. this aims to reduce the stigma surrounding mental illness, teach recognition of emerging symptoms and encourage access to appropriate services and processes, especially where individuals may be reticent about speaking to their line manager. adequate support and supervision for peer-supporters is essential, as they are vulnerable to being vicariously traumatised. taking learning from the military on operational deployments, tertiary prevention needs to be nimble 'forward psychiatry', and not practice as usual. accessibility and rapidity of service are important to determine whether individuals can return to work, possibly with advice or work adjustments, or whether a more formal assessment is required. the pies modelproximity, immediacy, expectancy and simplicityis an evidence-based occupational health approach supporting individuals to continue working where they can and building self-esteem so that they can cope with distress. this encourages keeping staff close to their front line, even if on altered duties; getting help before distress escalates into a crisis; a strengthsbased positive focus 'de-medicalising' normal responses in difficult times; and keeping interventions simple. in most staff, signs of ptsd will rapidly self-resolve, and the national institute for health and care excellence (nice) recommends 'active monitoring' without instigating treatment in most cases. mental health input will need to be ready to escalate, however, including commencing medication and working with primary care, occupational health, secondary and tertiary mental health supports. longer-term follow-up needs to be considered, not least as many staff will have been temporarily deployed to new sites and teams and will be returning to services that are unaware of their difficulties and needs. finally, there is a need for collection and sharing of learning and research. in the uk, the national institute of health research (nihr) holds an accessible central resource: https://www.nihr.ac. uk/covid-studies. the challenges of covid- are substantial and the longer-term healthcare and societal outcomes yet to be determined. moral injury and the development of mental illness are very real risks for staff working in unprecedented scenarios often well outside their ordinary levels of experience and training. this editorial provides an evidence-based model of support and care for staff and managers in these environments. we recommend a tiered model of inputs: good induction; building supportive 'buddy' relationships and managerial debriefs; appropriate environmental and 'virtual' well-being supports; and provision of rapidly accessible mental health professionals able to carry out timely 'return to duty'focused assessments and brief interventions. unless services take active measures and adopt a proactive 'nip it in the bud' approach, the psychological consequences of the pandemic on healthcare staff could be dramatic. managing mental health challenges faced by healthcare workers during covid- pandemic traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace trauma risk management (trim) in the uk armed forces frontline treatment of combat stress reaction: a -year longitudinal evaluation study national institute for health and care excellence. post-traumatic stress disorder (nice guideline ng ). nice the work was supported by the national institute for health research (nihr) health protection research unit in emergency preparedness and response at king's college london, in partnership with public health england and in collaboration with the university of east anglia and newcastle university. all authors meet all four icmje criteria for authorship and have approved the final version of this manuscript.declaration of interest n.g. runs a psychological health consultancy that provides resilience training for a wide range of organisations, including a few nhs teams. the views expressed are those of the authors and not necessarily those of the nhs, nihr, department of health and social care, or public health england.icmje forms are in the supplementary material, available online at https://doi.org/ . / bjp. . . key: cord- - zq tw authors: d’acci, luca s. title: urbanicity mental costs valuation: a review and urban-societal planning consideration date: - - journal: mind soc doi: . /s - - - sha: doc_id: cord_uid: zq tw living in cities has numerous comparative advantages than living in the countryside or in small villages and towns, most notably better access to education, services and jobs. however, it is also associated with a roughly twofold increase in some mental disorders rate incidence compared with living in rural areas. economic assessments reported a forecasted loss of more than trillion dollars in global gdp between and and of around trillion for the year alone when measured by the human capital method. if we exclude self-selection processes and make the hypothesis to be able to level down the mental illness rate incidence in urban areas to these of the rural by better urban-societal planning, around € . trillion could be saved yearly worldwide. even a reduction of only % in urban mental illness rate would save around billion dollars yearly. disorders are also the primary cause of disability-adjusted life years worldwide (bloom et al. ) . decades of empirical research shows an association between mental health and urbanicity, especially for the individuals genetically more inclined and those who lived in cities during their early life. links, often proven to be causal by longitudinal and dose-response analysis, between urbanicity and mental illness have been greatly reported such as in these studies: coid et al. ; evans et al. ; vargas et al. ; sampson et al. ; lecic-tosevski ; reed et al. ; evans et al. ; castillejos et al. ; kirkbride et al. kirkbride et al. , cooper et al. ; besteher et al. ; gruebner et al. ; krzywicka and byrka ; vassos et al. ; newbury et al. ; brockmeyer and d'angiulli ; adli et al. ; freeman et al. , wilker et al. peterson et al. ; haddad et al. ; vaessen et al. ; steinheuser et al. ; haluza et al. ; krabbendam et al. ; streit et al. ; calderón-garcidueñas et al. ; heinz et al. ; bedrosian and nelson ; stevens et al. ; tandon et al. ; lederbogen et al. ; fonken et al. ; larson et al. ; galea et al. ; mcclung mcclung , meyer-lindenberg ; park et al. ; bowler et al. ; kelly et al. ; mortensen et al. ; levesque et al. ; gwang-won et al. ; tae-hoon et al. ; peen et al. peen et al. , van os et al. ; kennedy et al. ; bentall et al. ; march et al. ; joens-matre et al. ; fuller et al. ; graziano and cooke ; maas et al. ; mortensen a, b, a, b; weich et al. ; krabbendam and van os ; tsunetsugu and miyazaki ; wang ; sundquist et al. ; van os ; van os et al. ; mcgrath et al. ; harrison et al. ; caspi et al. ; frumkin ; allardyce et al. ; haukka et al. ; torrey et al. ; van os et al. ; eaton et al. ; schelin et al. ; marcelis et al. ; mortensen et al. ; marcelis et al. ; thornicroft et al. ; lewis et al. ; cohen ; eaton ; christmas ; faris and dunham ; white . paykel et al. ( , analysing data from almost ten thousand individuals (household survey of the national morbidity survey of great britain) via a logistic regression, reported "a considerable british urban-rural differences in mental health, which may largely be attributable to more adverse urban social environments". according to vassos et al. ( ) , the rate of incidence of nine types of psychiatric disorders is in average . times higher in the capital city than in the rural areas, with 'schizophrenia and related disorders' even almost double ( . ), while the review of mcgrath et al. ( ) of studies found a schizophrenia incidence rate times higher in urban areas than in mixed rural/urban areas; a rate that rises up to a . times greater risk of schizophrenia when one has lived years of her early life in a capital city rather than a rural area (pedersen and mortensen a) . peen et al. ( ) reported an odds-ratio for mental disorders in very highly urbanized areas of . related to non-urbanized ( . when unadjusted by control variables). an approximatively twofold increase in psychosis risk associated with urbanicity is also confirmed in the following empirical studies: marcelis et al. ( marcelis et al. ( , , mortensen et al. ( ) , schelin et al. ( ) , allardyce et al. ( ) , pedersen and mortensen ( a, b) , van os et al. ( van os et al. ( , , harrison et al. ( ), sundquist et al. ( , pedersen and mortensen ( a, b) , kirkbride et al. ( ) , haukka et al. ( ) and torrey et al. ( ) . an increase as high as fourfold was found in eaton et al. ( ) . a meta-analysis review summarised that urban dwellers have a . times greater risk of mood disorders than non-urban (peen et al. ) . due to the type of the analysis conducted, the causality (rather than a reverse causation) of the nature of this link, emphasising that urbanicity has an etiological effect on mental health, has been underlined, among many, by march et al. ( and lederbogen et al. ( ) . if we shift our attention to people's preferences toward places to live their lives, "many surveys about quality of life in cities invariably suggest that it is in smaller cities that the highest quality of life is achieved" (batty , p. ) . similarly, to european surveys, % of americans voted small towns/rural environments as the best kind of places to live and only roughly one in five ( %) voted cities (knox and pinch ) . another questionnaire (d'acci ) reported that only % of respondents prefers to live in a city rather than (ceteris paribus) in a natural environment ( %), in a town/village ( %), in a suburb ( %), while % of them were indifferent. in line with these stated residential preferences, happiness seems to decrease when urbanicity levels increase (sander ; lawless and lucas ) , and studies about self-declared life satisfaction, psychological well-being in rich countries systematically show lower levels of life satisfaction in urban areas compared to the rural or less urban areas (viganò et al. ; easterlin et al. ; gilbert et al. ; helliwell et al. ; fassio et al. this discrepancy between rural and urban environments' influence on mental health, life satisfaction and happiness suggest that by re-organizing our socioeconomic urban daily life and the physical urban-regional structure itself, there would be a potential margin of reduction in the urban mental illness rates and an increase of life satisfaction and daily mood of urban dwellers. to convince governments, urban and regional planners, stakeholders and the ordinary population about the relevance of the issue, an economic translation of the costs that psychological effects that cities have to us, might help to make the topic more tangible. mental disorder costs go far beyond the direct costs (diagnostic and treatment); their economic costs assessment for the society as a whole should monetarily translate also the following indirect factors: increased chance of leaving school early, lower likelihood of achieving good and full-time employment, reduced quality of life for the individual and her loved ones. the monetary quantification of indirect costs on health usually follows the human capital method which measures the personal direct costs plus the amount of discounted earnings from lost productivity due to several reasons such as those listed above (doran and kinchin ; gustavsson et al. ) . early commencement mental disorders result to be statistically significantly associated with the interruption of secondary education (leach and butterworth ) , which in turn means less likelihood to be employed in higher skilled professions (schofield et al. ) . as expected, psychiatric disorders between the ages of and , after controlling for confounding variables, was statistically significantly (p value < . ) negatively linked with workforce participation, income and economic living standards at age , and, more generally, cumulative episodes of psychiatric disorders negatively affect life outcomes (gibb et al. ). however, a bi-directional causality might appear between mental health and labour force participations as once workforce participation is being affected, a dangerous positive feedback loop could start: you get mentally ill then you work less, and the more excluded from work the more mentally ill you might be (laplagne et al. ). this unemployment rate within the mentally ill population has being quantified to be as high as four times more than the healthy population, and when they work they are more inclined both to presenteeism (work with low productivity) and absenteeism (more leave for illness) (schofield et al. ). this psychological distress cost related to lower productivity has been estimated in to be a$ . billion (equivalent to roughly a$ . billion in ) per annum in australia (hilton et al. ) , and the individuals' loss due to depression has been assessed as a % lower income than their full-time counterparts, while those deciding to retire early because of their mental health issues have % lower incomes, which at a national aggregate level means us$ million in transfer payments, $ million in lost income taxation revenue, and almost $ billion in gdb, just in (schofield et al. ) . reports for canada (smetanin et al. ) assessed that in years ( - ) the cumulative costs related to mental illness could be around us$ trillion (based on us$ )-even if underestimated for the lack of some types of cost and of mental illness-and in - australia spent a$ . billion ( . % of all government health outlay) in mental health services by governments and health insurers. studies also estimate that personal family costs and lost productivity for businesses and other non-government organisation costs, equal, or even surpass, the total government expenditures (degney et al. ; hilton et al. ; jacobs et al. ) . the oecd report estimates as more than % of gdp (around € billion) the costs due to mental illness across europe (oecd ), while gustavsson et al. ( ) estimated it to be around € billion for the , including norway, iceland and switzerland to the european countries. a team of members from the world economic forum and the harvard school of public health (bloom et al. ) used different methods (although non comparable among each other) to estimate mental disorders costs: ( ) direct and indirect costs by human capital approach (the standard cost-of-illness method), ( ) impact on economic growth (macroeconomic simulation), and ( ) value of statistical life (willingness to pay). each method has a different approach: personal versus social, private versus public, yearly costs versus multiple years' cumulative costs. the human capital approach ( ), as we anticipated earlier, considers personal costs such as medical costs, transportation, care, income losses (related also to education loss due to illness), and sometimes it can also add non-personal costs such as public health education campaigns and research. the economic growth method ( ), also called the value of lost output, considers how the investigated diseases diminish labour, capital and any other factors involved in the gdp formation at the country level, focusing on the illness related mortality rates impact on gdp. the value of statistical life method ( ) is based on the people's willingness to pay (a kind of trade off) to lessen the risk of disability or death connected with the analysed illness, therefore by attaching an economic value to health/life itself it goes beyond the practical impact on gdp alone. the quantification is done either by observed trade-offs (e.g. in the labour market the wage premium a worker is willing to receive to take a job with a high injury-death risk, or the extra amount of money an individual spends for healthier food) and hypothetical trade-offs (surveys asking people how much they would pay to elude a risk or how much they would ask to take that risk). by method ( ) the team (bloom et al. ) estimated a world cost for mental illness of us$ . trillion for the year alone, and us$ trillion for the year alone, two-thirds of which for indirect costs. by method ( ) they estimated a world cumulative gdp loss of us$ . trillion (usa dollars ) due to mental health alone over years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . by method ( ) they estimated a world output loss of us$ . trillion in , and us$ . trillion in . converted into us$ for the year , they resulted approximatively us$ . trillion of gdp loss during the years between and ; us$ . trillion of human capital loss for the year alone; and us$ . trillion the willingness to pay for the year alone. all these estimates, even if already showing impressively high economic loss translations, are very likely underestimated (whiteford et al. ). it seems clear from decades of a reasonable amount of mutually confirming independent research that urban life has unfavourable (often hidden) effects on our psyche, especially for those genetically susceptible and for those exposed to urban contexts during their juvenile years when the brain is still developing, whose causality has been proven by longitudinal and dose-response studies. most people may not be aware about this psychological damage as it might be that the harm does not reach a sufficient entity to become visible, and that would remain below a certain level implying a manifested invisibility. yet, individuals might still suffer some kind of psychological uncomfortable feeling even without being able to define it, or, if so, to establish the direct link with their urban life. if it is indeed true that it is not 'only' a small percentage of genetically susceptible urban dwellers targeted by statistically significantly higher psychosis risks, but a larger urban population, although with consistent variability in magnitude, we need to include this type of mental costs within any cost-benefit alike analysis. territorial and urban planners cannot ignore the negative consequences that cities and territories have on our psychological well-being and mental health when poorly planned, designed and managed (e.g. endless cementification, lack of daily natural contact, congestion, lack of sky view, crowding, visually and socially boring dormitory areas extended for hectares, …). the same is valid for actions enabling us to change our socio-economic systems toward a more liveable scenario: just to cite an example, teleservices and teleworking (i.e. working remotely from home or wherever), a practice more and more in use and even becoming law (since july , first case in europe and probably in the world) in the netherlands if the worker wishes, would dramatically improve quality of life, free time, work efficiency and productivity, and enormously reduce congestion, daily car use, pollution, car parkstreet space, carbon emissions, and so on. similar effects would be induced by flexible personalized working times (following personal biological circadian rhythmsessential for health and productivity-and private life schedules) and reduction of national daily working hours from, e.g. from to h: equivalent or probably even higher productivity thanks to more efficient use of working time, concentration, positive mood and an overall physical and psychologically healthier population. probably a substantial help will come from medical genetics, pharmaceutics and psychologic-psychiatric progress regarding non-modifiable risk factors such as age, sex and genetic make-up, and from urban-territorial planning and governance, politics and education regarding the modifiable risk factors such as environment (e.g. greener and less crowded-polluted cities) and life style (diet, sport, sleeping, hobbies, sociality, daily natural contact) part of it linked with the environment where one lives. according to the large amount of empirical research evidence we saw, we can quite confidently say that urbanicity determines an approximately twofold increase in psychosis risk. let's speculate that by planning better structural-infrastructural urban environments and forms (d'acci ) and their socio-economic systems/life styles, (eliminating crowd-congestion, pollution, greenless, noise, crime, overwork, stress, over-pace…) of our current cities we are also able to entirely reduce their extra psychosis incidences and then levelling the urban psychosis rate to the rural one. if we refer to the cost-of-illness method (human capital) which directly involves money actually spent in mental illness issues, us$ . trillion would be use for mental urban costs in year alone ( , when, according to un , a . % of urban population is expected). if we prefer to avoid forecasts so far away in time ( ) and refer our thoughts only to real data from the past, in the money actually spent for mental illness was us$ . trillion worldwide ( dollars). an amount also in line with the % of gdp costs for mental illness assessed by the oecd regarding europe: in fact if we use this gdp percentage at the world level, the world gdp in was around (in current dollars) us$ . trillion, whose % means us$ . trillion, namely around us$ . trillion in dollars. by following the previous reasoning about levelling the urban psychosis incidence to the non-urban one thanks to better urban planning and socio-economic life styles, the share of world urban population in was around . %, therefore us$ trillion could have been saved in urban mental illness costs in that year alone. in the world urban population was around . % and the world gdp around us$ . trillion (current dollars), meaning roughly us$ . trillion today, whose % is around us$ . trillion which, following the same approximate reasoning (and assuming a similar percentage of gdp use) means that roughly us$ . trillion could have been not spent in mental illness due to urbanicity issues. if we assume a reduction of "only" % of urban mental illness rate, we would still save around billion dollars yearly. to put these trillions in context, the entire apollo space program ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , including the walks on the moon, still one of the major humanity achievements, costed only around us$ billion (in dollars); almost times less than what can be saved in only year in mental illness due to urban life. an equivalent program but on mars (sending nine crews), could cost around us$ . trillion, while the mars rover mission costs 'only' between and us$ trillions. another colossal human achievement, the year human genome project costed 'just' us$ . billion ( adjusted into dollars ). cities are a potentially great place to live and achieve our life's goals and progress, both as individual and as a species; however, it has some mental costs for the most susceptible. by planning better cities, territories and socio-economic daily life styles such as teleworking plus flexible working times, weekly working hour national reductions, greening cities and radically 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during – march to test the effect of the exposure level on mental health problems. our sample comprised participants who reported their perceived threat, coping efficacy, mental health problems and other demographic variables. multiple mediators path analysis was used in the data analysis. results: the results showed that the level of exposure to covid- in china was negatively associated with mental health problems, which confirmed the “psychological typhoon eye” effect. further analyses indicated that both perceived threat and coping efficacy partially mediated the relationship between them. however, coping efficacy explained the “psychological typhoon eye” effect. perceived threat mediated the positive relationship between exposure level and mental health problems. conclusion: this study detected the psychological typhoon eye effect and demonstrated the mediating role of coping efficacy and perceived threat between exposure to covid- and mental health problems. our findings suggest that policy makers and psychological workers should provide enough psychological services to low-risk areas as the high-risk areas. an important means of alleviating mental health problems is to improve coping efficacy. the recent outbreak of coronavirus disease in china and worldwide is a major public health emergency of international concern and has been characterized by the world health organization as one of the most challenging outbreaks to date. as of june , around . million confirmed cases globally, , in china, with , deaths ( . %) had been reported by the who. reviews in the field of exposure to covid- and mental health problems have called for research to test the relationship between them and to identify the mechanism underlying this relationship [ , , ] . the present study examined the risk perception factors that may explain how the level of exposure to covid- in china contributes to mental health problems. many organizations and researchers have highlighted concerns about mental health problems in affected communities. major public health emergencies, such as the severe acute respiratory syndrome coronavirus (sars-cov) in , the middle east respiratory syndrome coronavirus (mers-cov) in , the west africa ebola virus disease (evd) pandemic in - , and the global covid- pandemic typically lead to widespread fear and panic. for example, a critical review indicated that sars survivors consistently reported high rates of emotional distress persisting for years [ ] . during the west africa evd pandemic, there were increasing risks for new-onset psychological distress and psychiatric disorders [ ] . psychosocial effects include adjustment disorders, symptoms of ptsd, anxiety, and depression [ , , ] . to date, several studies have indicated the influence of covid- on mental health problems. for instance, the pandemic has burdened a major psychological stress on the medical workforce [ ] and could cause distress and leave many people vulnerable to mental health problems and suicidal behavior [ ] . thus, the influence of covid- on mental health problems cannot be ignored. to manage psychological sequelae, it is important to detect the antecedents of mental health problems. the antecedents of mental health problems during public health emergencies include many factors, such as the exposure level, quarantine, social support, social rejection or isolation, and the news media conveying risk-elevating messages about the public health crisis [ , , , ] . specific to covid- , some studies have revealed that risk perception, health anxiety, social media use and more media engagement are predicators to mental health problems [ , , ] . among these factors, an obvious objective variable is the extent to which people are exposed to emergencies and disasters in their daily life, i.e., the exposure level. according to the ripple effect found in the seminal study by slocvic ( ) , the impact of an unfortunate event decays gradually as ripples spread outward from the center; the closer people are to the center (i.e., the higher the exposure level), the stronger their mental distress is. however, a few studies have found that this is not the case [ , ] . studies have found that proximity to the center of the epidemic or devastated area was negatively related to anxiety levels [ ] , epidemic-related safety and health concerns [ ] . this phenomenon was termed the "psychological typhoon eye" effect to describe the public's psychological response, e.g., anxiety levels, safety and health concerns, to major emergencies and disasters. to date, the "psychological typhoon eye" effect has been detected after the wenchuan earthquake [ ] , during the sars epidemic [ ] and in relation to leadzinc mining risk [ ] . researchers have proposed three major possible explanations for this effect [ ] . the first explanation is psychological immunization theory, which assumes that resistance to a stressful event is naturally acquired through repeated exposure [ ] . people become desensitized by repeated exposure and can better prepare for stressful events. the second explanation is cognitive dissonance theory [ ] . cognitive dissonance is an uncomfortable psychological state in which the individual attempts to restore consistency or consonance by changing his or her beliefs and attitudes. when someone is at risk or in crisis, it is easier to change their beliefs and attitudes towards potential risk than to change their location [ , , ] . thus, people who are at the center of emergencies and disasters are presumably more likely than people living far away to believe that the risk is low and therefore continue to live nearby. the third explanation is the gap between experiencing/involving and imagining [ , ] , in which people in the center have a more accurate estimate of the risks based on real experience and involvement. to date, few empirical studies has tested these explanations. however, all the explanations suggest that the influence of the level of exposure to an unfortunate event on mental health problems may be mediated by subjective risk perceptions. risk perceptions are intuitive risk judgments [ ] that include "the process of collecting, selecting, and interpreting signals about uncertain impacts of events, activities, or technologies" ( [ ] , p. ). a meta-analysis by sheeran and his colleagues showed that risk perceptions have a close association with people's health behavior [ ] . according to protection motivation theory (pmt [ ] ;), health attitudes and behavior depend on two key psychological factors of risk perception, including one's perceived threat due to the risk and coping efficacy with regard to the ability to cope with the risk. perceived threat consists of estimates of the chance of contracting a disease (perceived vulnerability) and estimates of the seriousness of a disease (perceived severity). coping efficacy refers to beliefs about whether responses are available and effective in averting the threat (response efficacy) and whether people and groups can effectively respond to the risk and protect themselves from the hazard (self-efficacy). to a great extent, the three explanations for the "psychological typhoon eye" effect emphasize the role of coping efficacy in risk perceptions. the essence of psychological immunization is an increase in coping efficacy. with repeated exposure, individuals develop new patterns of coping to deal with the crisis. these patterns become an integral part of their repertoire of problemsolving responses and increase the likelihood that these individuals will deal more or less realistically with future hazards. in this way, the satisfactory resolution of one crisis increases resistance to subsequent adverse experiences [ ] . similarly, the essence of the gap between experiencing and imagining is that people in the center have high response efficacy and self-efficacy when they have a large amount of embodied experience or involvement compared with those without experience or involvement. additionally, cognitive dissonance theory emphasizes that after applying the cognitive strategies of rationalization (i.e., restoring consonance), the coping efficacy of people in the center is strengthened. among the three explanations, coping efficacy may be viewed as an internal mental indicator of psychological immunization. cognitive dissonance and experience act as two pathways to enhance people's coping efficacy. the former is a cognitive pathway and the latter is a behavioral pathway. the goal of this research was twofold. the first goal was to examine the robustness of the "psychological typhoon eye" effect during the covid- epidemic: the closer people are to the "center" of the epidemic (i.e., the higher the exposure level), the less serious their mental health problems are. to our knowledge, two studies have confirmed the "psychological typhoon eye" effect with regard to the level of exposure to epidemics and mental health problems. these studies examined the relationship between the level of exposure and anxiety levels [ ] and epidemic-related safety and health concerns [ ] . in this study, we assessed mental health problems using a questionnaire adapted from the psychological and behavioral questionnaire for sars [ ] . the questionnaire was designed to reflect the psychological state of the population during severe public health emergencies. it consists of five dimensions, i.e., depression, neurosism, phobia, compulsion-anxiety, and hypochondriasis. compared to the two studies stated above, this study investigated broader facets of mental health problems rather than one specific aspect. the second goal was to investigate the mechanism of the "psychological typhoon eye" effect. as stated before, even though some possible mechanisms have been proposed, none of them have been verified by empirical studies. we draw on protection motivation theory to formulate a theoretical model of how the exposure level during the covid- epidemic influences mental health problems. according to protection motivation theory, we hypothesized that the association between the exposure level during the covid- epidemic and mental health problems was mediated by both individuals' perceived threat of covid- risk and their coping efficacy (see fig. ). more importantly, we hypothesized that the valence of the mediating effects was distinct. both perceived threat and coping efficacy are positively correlated with the exposure level. however, perceived threat, which tends to aggravate mental health, is positively correlated with mental health problems. this hypothesis is based on evidence from sars studies and covid- studies. these studies showed that the relatively high perceived threat (severity and vulnerability) of sars/covid- played a pivotal role in the development of fear for the pandemic [ ] or psychological distress [ , , ] and increased the odds of individuals having a high level of depressive symptoms years later [ ] . in contrast, we hypothesized that coping efficacy, which tends to buffer mental health, is negatively correlated with mental health problems. this hypothesis is based on the fact that numerous studies have indicated fig. proposed model of exposure level, risk perception and mental health problems that self-efficacy is an effective factor to cope with a crisis and buffer psychological distress [ ] . a crosssectional study of respondents in a community health care setting showed that mental health status was negatively correlated with coping strategies, which can increase self-efficacy [ ] . a systematic review article [ ] found that psychological distress was prevalent among ebola survivors, whose coping strategies included engagement with religious faith, ebola survivor associations and involvement in ebola prevention and control interventions. all of these coping strategies are beneficial to enhance self-efficacy and response efficacy to relieve psychological distress. additionally, both qualitative and quantitative studies suggest that social support is an effective coping strategy for psychological distress [ ] because it can promote self-efficacy [ , ] . to achieve the two aforementioned purposes, we conducted a survey in provincial-level administrative divisions of china during - march . our first hypothesis is that a "psychological typhoon eye" effect exists between the level of exposure to epidemics and mental health problems. the second hypothesis is that there are two parallel routes between the exposure level and mental health problems. specifically, perceived threat mediates the positive relationship between the exposure level to epidemics and mental health problems, while coping efficacy mediates the negative relationship between them. in other words, coping efficacy could account for the "psychological typhoon eye" effect. the online survey platform wenjuanxing (https://www. wjx.cn) was employed to conduct this study during an eleven-day period ( - march ). the platform is a usable platform for user studies [ , , ] . in total, participants from provincial-level administrative divisions took part in the survey. the data of participants who did not complete the survey seriously (average answer time less than ms per question or answering repetitively for every question) were excluded. the final number of effective samples was . this study was approved by the school of sociology and psychology academic committee, central university of finance and economics. it takes around mins to complete all questionnaires in this study, and participants received five rmb after their participation. the mental health questionnaire was adapted from the psychological and behavioral questionnaire during sars [ ] , which was designed to reflect the psychological state of the population under severe public health emergencies. the adaptations made the items specifically applicable to covid- . twenty-five items were categorized into five dimensions: depression (α = . ; e.g., "i am easily fatigued and have difficulty recovering"), neurosism (α = . ; e.g., "i am interested in nothing"), phobia (α = . ; e.g., "i avoid going to hospitals or other crowded areas as much as possible and wear a mask when meeting people"), compulsion-anxiety (α = . ; e.g., "i have symptoms including rapid heartbeat, sweating and blushing"), and hypochondriasis (α = . ; e.g., "i worry about being infected when i have related symptoms"). all the items were measured on -point scales from to according to the level of emotion (none, mild, moderate and severe) or frequency of behavior (occasionally, sometimes, often, always). we averaged the scores to obtain a score for every dimension (possible score range: - ). we averaged the ratings to obtain the scores for each dimension and the overall mental health score (α = . ). the accumulative number of confirmed cases was regarded as an indicator to evaluate the severity of the covid- epidemic compared with other epidemic indicators (e.g., accumulative number of deaths, incidence rate, case fatality rate; see details in table ). all epidemic data were acquired from the official website of the national health commission on march nd, , and this website is the most authoritative website for information on the epidemic during the covid- in china. this study used the accumulative number of confirmed cases to represent the exposure level during covid- , see details in table . the perceived threat questionnaire was selfconstructed based on the model of risk perception by slovic [ ] . this questionnaire was designed to reflect perceived vulnerability and perceived severity during the outbreak of covid- . a total of six items were used to measure perceived threat initially. all the items were measured on a -point scale from (strongly disagree) to (strongly agree). item descriptions, and reliability and validity of variables can be seen in tables and . one item "i follow the official information released by the national health commission frequently" was removed due to its loading below . [ ] , so five items were used to represent perceived threat in final structural model. the discriminant validity results according to the fornell-larcker criterion are shown in table . the coping efficacy questionnaire was adapted from the perceived coping efficacy questionnaire used by kim, sherman and updegraff [ ] , which was designed to reflect the participants' belief that they and their groups could effectively protect themselves from the threat of ebola. the adaptations made the items specifically applicable to covid- . coping efficacy in the present study involves self-efficacy and response efficacy, and the four items are "i think the pneumonia epidemic will be effectively controlled", "i am optimistic about the situation of this epidemic", "i believe that i can effectively deal with the pneumonia epidemic" and "i believe we can effectively deal with the pneumonia epidemic". the first two items mainly reflect response efficacy, while the last two items mainly reflect the self-efficacy. four items were measured on a -point scale from (strongly disagree) to (strongly agree), and all of items have high reliability and validity, see details in tables and . the following covariates were included in the current study: data was analyzed using spss . , and structural models among exposure levels, perceived threat, coping efficacy and mental health problems were used by partial least squares structural equation modeling (pls-sem) in smartpls . (smart pls gmbh). pls-sem has often been recommended for data analysis in the case of nonnormal data [ ] . in this study, original number of cases in the provincial regions had great variances, and it doesn't conform to a normal distribution. for example, hubei province had , accumulated cases of covid- in march, while the accumulated cases in other provincial regions were under , see details in table . significance testing at the . level (two-tailed) in pls-sem were generated by using subsamples. the fig. was negatively related to mental health scores of people in provinces in china, r = − . , p < . . the correlations among the exposure level, risk perception and mental health problems during covid- are presented in table . the exposure level was negatively related to mental health problems, p< . . moreover, perceived threat was positively correlated with mental health problems, and coping efficacy was negatively related to mental health problems, ps < . . furthermore, the mediating effects of risk perception between exposure levels and mental health problems were tested using the pls-sem in smartpls. we generated bootstrapping subsamples from the original data set (n = ). table displays the direct and indirect effects after controlling for age, gender, income, educational level, and occupation (as covariates). the model explained . % variance in mental health problems. as shown in fig. , the exposure level exerted a significant indirect effect on public mental health via perceived threat and coping efficacy. the present study examined whether and how the level of exposure to covid- in china influenced mental health problems. the results showed that the exposure level to covid- in china was negatively associated with mental health problems related to covid- . specifically, the higher the exposure level to covid- , the better mental health was. more importantly, this study is the first to reveal the mechanism by which the level of exposure to covid- is linked to mental health problems related to covid- . specifically, perceived threat our finding of less serious mental health problems related to covid- for people with higher exposure levels to covid- in china confirms the psychological typhoon eye effect rather than the ripple effect. this finding is consistent with several previous studies [ , ] of public emergency events in china, which reported that proximity to the center of the epidemic or devastated area was negatively related to the public's irrational panic and mental distress. additionally, this finding is in accordance with a counterintuitive phenomenon in which intense states, such as emergency events, may abate more quickly than mild states because intense states trigger psychological processes that are designed to attenuate them [ ] . this phenomenon is an instance of a more general phenomenon known as the region-β paradox, which demonstrates that the relation between time and distance is nonmonotonic since people tend to use faster modes of transportation to cover longer distances [ ] . according to our findings, the underlying mechanism is that coping efficacy mediates the negative relationship between the level of exposure to covid- and mental health problems. in other words, it is the coping efficacy that accounts for the psychological typhoon eye effect. theoretically, as mentioned above, all explanations in previous studies, including the psychological immunization theory, cognitive dissonance theory, and the theory of the description-experience gap [ , ] , have emphasized the essential and potential role of efficacy. in the framework of psychological immunization theory, people in areas of high exposure would acquire more self-efficacy to cope with the epidemic because people become desensitized after repeated exposure. in this sense, their immunization ability is improved. similarly, in the framework of the description-experience gap theory, a more accurate estimate of the risks based on real experience and involvement increases the sense of control and efficacy. in the framework of cognitive dissonance theory, individuals apply the cognitive strategy of rationalization to achieve a state of consonance to restore a sense of self-control and selfefficacy. generally, people fail to anticipate the extent to which their psychological immune systems will hasten the recovery from disaster or major negative events, which is termed immune neglect [ , ] . as such, the triggered psychological process, i.e., the cognitive strategy of rationalization, helps individuals reduce negative states more quickly, which in turn subjectively enhances self-efficacy. in summary, all three explanations in previous studies directly or indirectly emphasize the role of efficacy, which is a pivotal factor in our model. the mediating role of coping efficacy can be easily understood in the context of collectivist chinese culture. in collectivist countries, when the public is exposed to the center of an epidemic or devastated area, a high level of coping efficacy is stimulated [ , , ] . appropriate response efficacy at the national level provides sufficient information and psychological support for the public, which in turn increases coping efficacy. additionally, many empirical studies have shown that self-efficacy is an effective factor to buffer psychological distress (e.g., [ , , ] ) and that response efficacy is positively correlated with health behavior (e.g., [ , ] ). this study also showed that the perceived threat of covid- was positively related to mental health problems related to covid- , which is consistent with previous evidence in relation to sars (e.g., [ , , ] ). furthermore, perceived threat mediated the positive relationship between the level of exposure to covid- and mental health problems related to covid- . specifically, this finding can explain the ripple effect (i.e., the higher the exposure level, the stronger the mental distress). however, considering the specific results of this study (i.e., the negative relationship between the exposure level and mental health problems), perceived threat may be a suppressor in the negative relationship. taken together, the two pathways suggest that the two mechanisms work simultaneously, but the valence of the indirect effects is reversed. in summary, coping efficacy rather than perceived threat could explain the psychological typhoon eye effect. regarding the psychological typhoon eye effect and the ripple effect, we preliminarily speculate which effect dominates may be a result of balance between perceived threat and coping efficacy. they can be seen as two sides of seesaw. when perceived threat is too high and coping efficacy is too low, people may experience the overwhelming fear and hopelessness [ ] . when coping efficacy is too high and perceived threat is too low, people may underestimate the risk and not adopt coping strategies to avert the threat. only when perceived threat is high enough to arouse coping efforts, and is nearly comparable to coping efficacy, both of them function greatly and they may dominate the seesaw alternatively. depending on which one is higher between coping efficacy and perceived threat, mental health problems related to the stressful emergency demonstrate the psychological typhoon eye effect or the ripple effect. when coping efficacy is higher than perceived threat, the related mental health problems may demonstrate the psychological typhoon eye effect; when coping efficacy is lower than perceived threat, the mental health may demonstrate the ripple effect. our data were collected on - march when the number of new cases decreased to single digits and scientific prevention and control as well as orderly resumption of work and production was promoted. perceived threat should be slightly lower than coping efficacy. therefore, the psychological typhoon eye effect was seen in our study. our assumptions can be used to understand some phenomena. for example, although cyberchondria is generally regarded to be negative, in the case of covid- , it might have made people understand the threat of the situation [ ] . however, when constantly seeing news and reports highlighting the threat of covid- , people will start to suffer from stress and anxiety [ ] . we can imagine that by seeking news and reports highlighting coping efficacy, people's mental health states may be better when their coping efficacy is increased to be higher than perceived threat. taken together, emergency management like covid- demands dynamic balance between perceived threat and coping efficacy [ , ] . however, our speculations are very preliminary and remains to be tested empirically in future studies. overall, this study confirmed the psychological typhoon eye effect during the outbreak of covid- in china and demonstrated the mediating role of coping efficacy and perceived threat between exposure to covid- and mental health problems. our findings suggest that policy makers and psychological workers should provide enough psychological services to low-risk areas as the high-risk areas. an important means of alleviating mental health problems is to improve coping efficacy. however, our findings may be restricted to people during an epidemic who live in collectivist countries. it remains unclear whether our findings are applicable in other countries or after the epidemic. china is a typical collectivist country. people in the center of outbreaks in china obtain intensive and extensive social support from the government, enterprises, individuals and society. therefore, coping efficacy can play an important mediating role. it is not clear whether our findings hold true in other countries. more studies in other countries are needed to confirm our findings. in addition, our results cannot exclude the possibility that people in the center of emergencies and disasters are occupied with coping, and therefore some types of mental health problems emerge only after the epidemic. some longitudinal studies have indicated that sars survivors still had elevated stress levels and worrying levels of psychological distress even after to years [ , ] . medical staff who performed mers-related tasks showed the highest risk of posttraumatic stress disorder symptoms even after time had elapsed [ ] . therefore, although we observed a negative correlation between the level of exposure and mental health problems, we do not suggest stopping or reducing psychological assistance to people in the center of the outbreak. psychological workers and policy makers should provide appropriate psychological services depending on the level of exposure and epidemic stage. finally, this study did not directly test the associations between coping efficacy and three explanations including psychological immunization, cognitive dissonance and description-experience gap. thus, these specific claims regarding their associations are more speculative, which would need to 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of medical staff treating patients with coronavirus disease (covid- ) in january and february in china the 'typhoon eye effect': determinants of distress during the sars epidemic proposals for coping with "psychological typhoon eye" effect detected in covid- the more involved in lead-zinc mining risk the less frightened: a psychological typhoon eye perspective publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations not applicable.authors' contributions lz and zx conceived and designed the study. dl performed the survey. mm and ld analyzed the data. lz and mm wrote the paper. the authors read and approved the final manuscript. the raw data supporting the conclusions of this manuscript will be made available by the authors to any qualified researcher. this study was approved by the administration committee of psychological research in central university of finance and economics and was in compliance with the ethical guidelines of the american psychological association. each participant signed the informed consent. not applicable. all of the authors do not have any interests that might be interpreted as influencing the research.received: june accepted: september key: cord- - ve heyb authors: maulik, pallab k.; thornicroft, graham; saxena, shekhar title: roadmap to strengthen global mental health systems to tackle the impact of the covid- pandemic date: - - journal: int j ment health syst doi: . /s - - - sha: doc_id: cord_uid: ve heyb background: the covid pandemic has been devastating for not only its direct impact on lives, physical health, socio-economic status of individuals, but also for its impact on mental health. some individuals are affected psychologically more severely and will need additional care. however, the current health system is so fragmented and focused on caring for those infected that management of mental illness has been neglected. an integrated approach is needed to strengthen the health system, service providers and research to not only manage the current mental health problems related to covid but develop robust strategies to overcome more long-term impact of the pandemic. a series of recommendations are outlined in this paper to help policy makers, service providers and other stakeholders, and research and research funders to strengthen existing mental health systems, develop new ones, and at the same time advance research to mitigate the mental health impact of covid . the recommendations refer to low, middle and high resource settings as capabilities vary greatly between countries and within countries. discussion: the recommendations for policy makers are focused on strengthening leadership and governance, finance mechanisms, and developing programme and policies that especially include the most vulnerable populations. service provision should focus on accessible and equitable evidence-based community care models commensurate with the existing mental health capacity to deliver care, train existing primary care staff to cater to increased mental health needs, implement prevention and promotion programmes tailored to local needs, and support civil societies and employers to address the increased burden of mental illness. researchers and research funders should focus on research to develop robust information systems that can be enhanced further by linking with other data sources to run predictive models using artificial intelligence, understand neurobiological mechanisms and community-based interventions to address the pandemic driven mental health problems in an integrated manner and use innovative digital solutions. conclusion: urgent action is needed to strengthen mental health system in all settings. the recommendations outlined can be used as a guide to develop these further or identify new ones in relation to local needs. page of maulik et al. int j ment health syst ( ) : community structures across the globe is potentiating a major international mental health crisis [ ] [ ] [ ] [ ] . the mental health impacts of covid- can be varied and severe and have been outlined recently [ ] . the effect of this stress can vary from mild symptoms related to physiological or psychological functions such as sleep disturbance or low mood, mild stress for short periods of time that do not need any specific treatment and resolve when the primary stressors such as job loss or illness in family or poor social support are taken care off, to the more severe syndromal mental disorder which may need formal treatment from a mental health professional [ ] . anxiety, depression, increased alcohol and substance use, irritability, anger, insomnia and increased risk of suicide have been reported, as have been risk factors for mental disorders such as loneliness, domestic violence, physical violence. individuals with existing mental disorders such as alcohol and substance use, cognitive impairment and dementia, childhood psychiatric disorders and adults needing long term follow up have been particularly affected due to lack of continued psychiatric care services and fragmentation of the existing health systems to provide adequate care. in addition, the direct impact of covid on mental illness of those infected or health workers involved in care of those infected is also significant, and is often precipitated due to increased stigma, social isolation and quarantine [ ] . all this is even more complicated due to the socioeconomic impact of the pandemic on the lives of the poor and most disadvantaged communities such as homeless and migrant workers. the overall mental health impact of the pandemic is not transient but likely to continue for a long period even after the pandemic ends, as is evident from prior research on such severe epidemics [ , ] . researchers have highlighted the need for focussed research that should be funded related to the impact of covid- [ ] . most mental health systems across the world have been woefully inadequately funded, planned, organised and delivered given the major global burden of mental disorders [ ] . the codid- pandemic has added even greater challenges. with shrinking economies, policy makers will have to rebalance prioritizing mental health services against other health service investments. the ability to react and take appropriate decisions will depend on the existing resources and infrastructure. these decisions will then need to be matched up against the impact of the pandemic-not only on mental health, but to the overall health of the country, as well as the socioeconomic determinants. thus, it becomes important to have a better understanding of what steps can be taken in such scenarios to make most efficient use of the limited resources. at the same time new research should align with the changing paradigm of mental health care delivery which may have to rely on use of digital solutions [ ] , identify risk factors that are particularly relevant to precipitating mental disorders in the face of this pandemic, and develop and implement scalable interventions to mitigate the impact of the infection on mental health across different communities and different settings. in this context, the aim of this paper is to outline a roadmap to guide countries to strengthen mental health systems to tackle the increasing burden of mental disorders. using both world health organization's mental health action plan - [ ] and the who health systems strengthening framework [ ] , we propose a set of recommendations from the perspectives of policy makers, service providers and research funders, organised into low-, middle-and high-resource scenarios. while the recommendations encompass systematic and structural actions that are relevant to building a strong mental health system per se and is essential to the current pandemic as in any other crisis, embedded within them are some more specific aspects that are particularly relevant to the covid crisis, and these have been indicated separately. the eventual objective is to "build back better" [ ] . table shows recommendations for policy makers in areas of leadership and governance, finance, policies and programmes that include long term care and needs of vulnerable populations. table outlines recommendations for service providers and other stakeholders involved in care of those with mental health problems. it focuses on providing equitable and accessible community-based mental health services and clinic-based services for those needing such care, build capacity by training primary care health workers to provide community-based services, implement community-based mental health prevention and promotion programmes, strengthen civil societies to support the government mental health service provision, and support programmes and policies specifically to manage workplace related stress which will be a major issue given the economic woes and changing paradigms of limited workforce or working from home. table outlines recommendations for researchers and research funders to align research to strengthen information systems, gather more epidemiological data and conduct robust interdisciplinary interventions that are scalable, use innovative designs and leverage technology to develop some interventions to facilitate service delivery and improve supply chain of psychotropic medications at primary care levels and leverage the power of social media to deliver interventions. technology strengthen civil societies *civil societies identify key areas where they can contribute and pitch into support the overall government plan to manage mental health problems during the covid pandemic *civil societies involved in mental health service delivery or research or advocacy are identified and integrated within a government database; especially those with the ability to support multiple health conditions including mental health should would be beneficial the databases of civil societies allow the administrators to identify strengths of each organization, its reach, focus, and key resource person(s) government plans their mental health alleviation programmes keeping civil societies in the loop and takes their opinions government allocates ring-fenced funds to support activities undertaken by civil societies where it by itself cannot function effectively, be it research, program implementation, or advocacy *a registry of civil societies is advanced enough to allow for an easy two-way communication between them and the government *appropriate funds to support civil societies led programmes are present and those are planned in consultation with the government civil societies per se can access resources and roll out programmes as per their strengths while keeping the overall focus on managing the impact of the pandemic the collaborations between civil societies and government is streamlined; the government provides oversight to local and regional programmes that are essentially implemented by civil societies *civil societies and government are equal partners in delivering care or conducting research during this pandemic *civil societies working at national, regional or local levels are adequately funded to support not only their own activities but support government efforts to overcome the covid pandemic develop innovative solutions to improve mental health systems; support technologyenabled solutions to support service delivery; identify strategies to enable more efficient supply chain logistics models for medicines; use of social media to deliver interventions on mental health promotion *develop technology-enabled solutions to conduct research and gather data avoiding in-person contact as much as feasible, while ensuring appropriate data security and privacy *identify culturally relevant evidence-based applications to gather data on mental health outcomes and increase access to care conduct health systems research to investigate how supply of psychotropic medications at community level can be accomplished use social media platforms to not only link researchers but also develop interventions based on use of social media *better ability to link secondary data from other sources with primary data using big data analytics *service use involves digital technology, interactive voice messages, video games, virtual reality *advanced methodologies using artificial intelligence driven analytics allow development of risk profiles in real time and identify predictive models led solutions need to be ramped up especially in these conditions where in-person data collection is limited considerably. mental health is one of the most neglected areas of health. the covid pandemic and any similar challenges in future, should be tackled along the lines of a humanitarian emergency [ ] . even during more normal times, addressing mental health needs as part of the sustainable development goals has been a major challenge [ ] . the covid crisis has led to a fragmentation of existing health systems across the globe, which will have a profoundly negative and cascading effect on mental health not only in coming months, but for some years, and this has been identified even at the united nations [ ] . not only will covid lead to a surge in mental health needs in the community [ , ] , but the way it has crippled the health systems globally to address the need of any other health problem, it is likely to have a devastating effect on the longer term needs of people who need care for mental illnesses [ ] . it becomes necessary to identify strategies to strengthen health systems to overcome these challenges. the best way to tackle mental health impact is to not limit it to overcoming the immediate mental health crisis, but to embed its management within the larger health system that can impact the lives of individuals globally or across large regions. in this paper we have focused on low, middle and high resource settings and indicated how they can re-orient their health systems, service provision and research according to the need and available resources. this approach applies as much to countries as it does to regions or health administrative units within countries, given the very large disparities in needs and resources that are common in countries worldwide. we present the recommendations in tables , and not as separate and unrelated proposals, but as part of an overall integrated approach to health system strengthening, which should be adapted to specific local needs and modified in relation to available resources. policy makers will play a major role in providing leadership to any programmes and policies that they develop and implement. it is therefore imperative that they are both educated about the mental health needs during this crisis and supported by academicians and mental health professionals to develop robust policies and programmes to address the increased burden of mental health. while there will be a requirement to address some immediate mental health needs and provide psychosocial support in line with the iasc guidelines [ ] , they should plan on developing more robust policies and programmes to build a system that is more holistic, encompasses intersectoral collaborations, protects the rights of the individuals, has deliverables that are based on evidence, and is able to deliver care over a long time. these policies and programmes should be supported by adequate funding and tap into existing private and government sources. insurance mechanisms should ensure that adequate financial support is available for individuals to seek mental health care as per need. this may need a paradigm shift in the way the insurance system is organized as most often mental disorders are excluded from their remit. in united states of america, telehealth parity has been introduced in many other states post the covid crisis to ensure providers get same payment for teleconsultations as in-person consultations, thus enabling service delivery [ ] . telepsychiatry has also resulted in expanding home-based care for conditions like substance use disorders in the united state, which earlier were only available if comorbid physical disorders were present. policy makers should support development of teleconsultations and robust electronic health records systems to enable remote care delivery. the mental health budget allocation should reflect the change in the burden due to the crisis and the government should be open to exploring innovative ways to build in mental health related budget into the relevant sectors, for example, addressing job security, providing affordable homes for migrant workers, building shelters for women or children facing abuse, enhancing care for the elderly and those with dementia, could help in reducing the burden considerably. strategies should be locally relevant and keep needs of vulnerable populations, inclusivity, stigma reduction, and rights-based approaches at the core of their principles [ ] . the key elements that service providers should keep in mind are to develop a model that is community-based and involves training and upskilling of primary health workers and non-mental health professionals to both identify and deliver basic mental health care based on principles laid down by existing guidelines [ ] , and drawing on basic tenets and the detailed guidance of the mhgap programme of the world health organization. psychological therapies can be tailored to the level of skilled resources available. the level of specialized care provided should be informed by local factors and available resources. some of those are number of mental health trained staff and their skills level, types of mental health facilities available, for example primary, secondary or tertiary care, budgets available to support services, availability of communitybased support services to cater to specific needs of individuals with significant disabilities, support services for families and caregivers, role of multi-sectoral agencies to support mental health care such as employment agencies, housing, elderly welfare, child welfare services, education. services provided should be locally tested and culturally relevant. needs of vulnerable populations should be specially kept in mind. the services should be both accessible and equitable, and one key strategy to ensure that in times of physical distancing could be increased use of technology enabled services such as e-health, m-health, telemedicine [ , ] . this should encompass screening, service delivery, training of health workers and monitoring. a key aspect is to maintain physical distancing while ensuring continuity of care. to do so telemedicine services and linking of patient and provider data on health information systems that enables tracking of a patient's health remotely is necessary. the system should allow both the patient and health providers to interact with each other either through video chats or dedicated phone lines and be interactive enough to allow the patient to upload their progress, treatment adherence and complications online and the provider can respond to those in real time. reports from italy, underline how mental health services were prioritized in the face of the covid pandemic by identifying essential mental health services, providing medications to those with substance use disorders, enabling teleconsultations [ , ] . even in low resource settings such as in india, teleconsultation for mental health issues is being regularly provided by many tertiary care centres, though there is a lot of scope for improvement. civil societies have also set up teleconsultation to care for emergency situations [ ] . in china, there were more specific challenges as being the first country to face the pandemic, there were no prior experiences to follow, but restructuring of service at different levels and delivering a mix of online and offline services were identified as critical for ensuring continuity of care, but new ethical challenges related to teleconsultations and practical problems related to implementation of new strategies had to be overcome [ ] . availability of psychotropic medicines should be facilitated by ensuring that the supply-chain is maintained, and governments need to invest for that specifically in low and middle resource settings. civil societies should be encouraged to collaborate with government agencies and work in both strategizing and service delivery and the government should allocate ring-fenced funds for such activities. labour organizations and employers should be adequately trained to identify specific mental health needs of individuals in this pandemic, but also encouraged to revisit their policies to ensure that their laws are employer friendly but also allowing for industry growth. addressing the mental health needs of employees is critical even in normal times [ ] and during this added challenge it may be a major factor to alleviate the burden as employees and employers both grapple with new situations of working from home, restricted office attendance, staff layoff, reduced productivity, and reduced remunerations. the focus of research and the level of sophistication of such will vary across low, medium and high resource settings. even within a high-income country there may be a need to understand how to deliver basic services or ascertain prevalence or incidence of mental disorders in some regions with lower resources. in order to capture the true burden of covid on mental health, it is vital that information systems to gather such data is strengthened across all settings. it is important to create a system where data from multiple sources can be linked to build an aggregate database involving both clinical and social determinants. an initiative on this, countdown global mental health is already underway [ ] . research exploring neurobiological correlates, behavioural concepts that determine how stigma and discrimination plays a role in help seeking in covid affected individuals, effect of socioeconomic policies on mental health, mental health effects on different populations by age groups, gender, migrant and labourer communities, homeless, health workers, etc., are all relevant areas of further investigation [ , , ] . research should also explore newer strategies using machine learning and artificial intelligence to build predictive models to inform risk profiles for future pandemics and determine possible phenotypes that could allow service providers to modulate care and overall outcomes. the role of artificial intelligence, digital tools to collect real-time data, combining online and off-line data with in-person data needs to be enabled to enrich research data to support better care models [ ] . we believe that urgent action is needed to strengthen mental health system in all settings in view of enhanced need for mental health care and decreased access during and beyond the covid- pandemic. the roadmap draws upon key sources and accumulated knowledge of mental health systems globally to provide a perspective on practical steps to strengthen mental health systems across the world. the strategies outlined here can be used as a guide to develop these further or identify new ones that are more applicable to local settings. taking no action in the face of increasing threats to mental health of populations is not an option in the covid era. the roadmap that we recommend here is intended to be used as a guide by policy makers, service providers and other stakeholders, researchers and research funders to develop strategies to actively improve mental health in relation to covid following the principle of building back better [ ] and deliberations of the national academy of sciences where suggestions were made to have person centred care, shared decision making and patient and family engagement [ ] , and to make mental health an integral part of the management of covid [ ] . covid- exposes the cracks in our already fragile mental health system policy brief: covid and the need for action on mental heath mental health and covid- : change the conversation addressing mental health needs: an integral part of covid- response mental health of communities during the covid- pandemic the lancet commission on global mental health and sustainable development posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a -year follow-up study psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid- pandemic multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science world health organization. mental health atlas global preparedness against covid- : we must leverage the power of digital health world health organization. mental health action plan - . geneva: world health organization world health organization. everybody business: strengthening health systems to improve health outcomes: who's framework for action. geneva: world health organization building back better: sustainable mental health care after emergencies. geneva: world health organization iasc guidelines on mental health and psychosocial support in emergency settings using telehealth to meet mental health needs during the covid- crisis rapid implementation of mobile technology for real-time epidemiology of covid- mental health services in italy during the covid- outbreak mental health services in lombardy during covid- outbreak challenges and recommendations for mental health providers during the covid- pandemic: the experience of china's first university-based mental health team workplace stress: a neglected aspect of mental health wellbeing countdown global mental health challenges and burden of the coronavirus (covid- ) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality covid- , mental health and aging: a need for new knowledge to bridge science and service commentary: an integrated blueprint for digital mental health services amidst covid- . jmir ment health key policy challenges and opportunities to improve care for people with mental health and substance use disorders: proceedings of a workshop addressing the public mental health challenge of covid- publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations received: june accepted: july authors' contribution pkm led the development of the manuscript and wrote the first draft and all subsequent drafts. gt and ss provided critical comments to the first draft and each subsequent draft. all authors read and approved the final manuscript. the authors declare that they have no competing interests. key: cord- -oegiq authors: cluver, lucie title: solving the global challenge of adolescent mental ill-health date: - - journal: lancet child adolesc health doi: . /s - ( ) - sha: doc_id: cord_uid: oegiq nan in the lancet child & adolescent health, daniel michelson and colleagues report the results of the first randomised controlled trial of a transformative research programme: premium for adolescents (pride) . the authors set out a vision of evidence-based, rigorously tested mental health services for adolescents in low-income and middle-income settings. these services are designed as a stepped series of interventions to be implemented at low cost, by lay workers, and at scale. in low-income settings globally, only a tiny fraction of adolescents with mental health distress will ever have access to psychiatric or psychological support. there is no question that this work is both essential and urgent. the trial compares two delivery mechanisms of a problem-solving intervention for common mental health problems. in very low-income urban indian schools, adolescents (aged - years) self-referred with clinical-level mental health problems. they received either lay counsellor directed sessions with accompanying comic-based booklets about problem solving and how to cope with common difficulties, or the booklets alone. although the booklet-only delivery was intended as a control group, both groups of adolescents showed reductions in overall mental health symptoms, functional impairment, internalising symptoms, externalising symptoms, and improved wellbeing. the group receiving additional lay counsellor support showed greater reductions in adolescentprioritised problems, and in perceived stress. it is remarkable that the rates of clinical remission for both groups were within the benchmarked range of - % for evidence-based psychological treatments. the findings of this study have important and wideranging implications. as the authors discuss, the booklets are likely to have been an active intervention, especially in low-resourced settings where adolescents were receiving no other mental health support. this observation supports initial evidence for the effectiveness of a low-intensity, low-resource mental health intervention that could feasibly be delivered at the population level in low-income settings. the results of the planned month post-hoc study and economic evaluation will help to inform and refine these findings. the study also shows the effectiveness of transdiagnostic approaches and common design principles in adolescent mental health, supporting the validity of moving beyond narrower diagnostic criteria to achieve wider reach without sacrificing clinical value. a core aspect of this work is the conscious effort of mental health research and service provision in joining forces with the education sector. the researchers recognise that reaching adolescents at the population level will not be achieved through health services alone. in india, where secondary school enrolment is high, this approach has exceptional potential to be scaled up. however, this approach could miss some of the most vulnerable adolescents, particularly in rural areas and among the poorest groups. in settings with lower adolescent school enrolment or gender differences in access to education, additional sectoral partnerships and innovative approaches will be necessary. this study might also indicate opportunities for the new realities we face in service provision. the study presents a scalable intervention that could be used when face-to-face counselling is challenged by physical distancing, school closures, and reduced timetables that restrict flexibility. the covid- epidemic has brought increased mental health distress among young people and new needs for mental health support, as well as an anticipated economic downturn that will hit hardest in low-income and middle-income countries. as options for remote learning are developed, the inclusion of mental health support within educational responses could be achievable and effective. at the unicef and who's leading minds conference in november, , vikram patel, the corresponding author of this study, threw down a gauntlet to the field of mental health: the overwhelming majority of children who already have mental health problems receive no recognition, nor any form of intervention that we know can transform their lives. the pride programme of research aims to develop low-cost scalable interventions for adolescents, and test them rigorously in high-poverty educational contexts. sangath-the non-governmental organisation leading this work-makes their interventions publicly and freely available online, setting a standard for other researchers and developers. their work provides a strong argument that mental health programmes developed by researchers should never be commercialised, but instead be considered a public good. the next challenge is achieving sustainability and scale, which will mean building coalitions with policy makers, funders, and advocacy groups, and further bridges beyond the health sector. sustainability and scaling up might require new research and testing of the effects of low-cost mental health interventions across sustainable development goal outcomes beyond health, such as school achievement, employment, and gender equality. expanding beyond india will also require careful assessment of acceptability and effectiveness in other low-resource regions. this study, and the wider programme of research that it is part of, are important steps to reaching adolescent mental health-care provision at scale. published by elsevier ltd. this is an open access article under the cc by oxford ox er, uk; and department of psychiatry and mental health effectiveness of a brief lay counsellordelivered, problem-solving intervention for adolescent mental health problems in urban, low-income schools in india: a randomised controlled trial development of a transdiagnostic, low-intensity, psychological intervention for common adolescent mental health problems in indian secondary schools treated prevalence of and mental health services received by children and adolescents in low-and-middleincome countries priorities and preferences for schoolbased mental health services in india: a multi-stakeholder study with adolescents, parents, school staff, and mental health providers protecting the psychological health of children through effective communication about covid- international bank for reconstruction and development/the world bank the lancet commission on global mental health and sustainable development a new vehicle to accelerate the un sustainable development goals key: cord- - lsyh s authors: purgato, marianna; uphoff, eleonora; singh, rakesh; thapa pachya, ambika; abdulmalik, jibril; van ginneken, nadja title: promotion, prevention and treatment interventions for mental health in low- and middle-income countries through a task-shifting approach date: - - journal: epidemiol psychiatr sci doi: . /s x sha: doc_id: cord_uid: lsyh s recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic ‘at risk’, to experiencing ‘mental distress’, ‘sub-syndromal symptoms’ and finally ‘mental disorders’. this new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder. this concept generated discussion on the distinction between prevention and treatment interventions, especially for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. the present editorial aims to clarify the definition of promotion, prevention and treatment interventions delivered through a task-shifting approach according to a global mental health perspective. the coronavirus pandemic has brought with it not only the physical sequelae of the viral infection but also rising levels of poverty, socioeconomic insecurity and physical and mental health problems worldwide. it is also postulated that the sars-cov virus may have neurological/ neuropsychiatric impact on the brain (holmes et al., ) . now more than ever, with rising mental health needs, it becomes even more important to find an effective solution to providing universal mental healthcare. strategies also need to be rolled out to tackle the root social, economic, environmental and psychological causes of mental ill health to prevent mental disorders and promote wellbeing. mental, behavioural and neuropsychiatric disorders all feature in the top causes of years lived with disability. the highest contributors are anxiety and depressive disorders, drug-use disorders and alcohol-use disorders (dalys and collaborators, ) . mental health and behavioural disorders contribute . % of the global burden of disease in the world, more than, for example, tuberculosis ( . %), hiv/aids ( . %) or malaria ( . %) (whiteford et al., ) . the contribution of major depressive disorders to worldwide disability-adjusted life years has increased by % from to and is predicted to rise further (prince et al., ; murray et al., ) . furthermore, self-inflicted injuries and alcohol-related disorders are likely to increase in the ranking of global disease burden due to the decline in communicable diseases and because of a predicted increase in war and violence. the disease burden due to alzheimer's disease is also increasing, linked to the demographic transition towards an ageing population . people living in low-and middle-income countries (lmics) are exposed to a constellation of stressors that make them vulnerable to developing psychological symptoms and/or mental disorders, and a large gap between individuals in need of care and those who actually receive evidence-based interventions still exists (world health organization, , . conceptualising mental health interventions is particularly relevant in settings with limited resources for interventions implementation. recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic 'at risk', to experiencing 'mental distress', 'sub-syndromal symptoms' (some symptoms suggested of a mental disorder but not sufficient to reach diagnostic categories) and finally 'mental disorders' (patel et al., ) . this new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder (tol et al., ) . at the same time, this concept generated discussion on the distinction between prevention and treatment interventions for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. the boundary between prevention and treatment is hard to draw in mental health. figure shows how staging has been conceptualised of mental health symptoms, together with where prevention and treatment interventions fit in. for example, wellbeing interventions are not just relevant to those who are asymptomatic as people with mental disorders can still work on and achieve a sense of wellbeing and quality of life and are therefore relevant across the stages (patel et al., ) . furthermore, these stages are not fixed or very well defined. minimal or early distress is a state which can often fluctuate and may not be affecting someone's functioning much yet whereas people with prodromal symptoms may well start to affect their function. in practice, differentiating which populations in the study are in these categories is difficult as the populations are often mixed. this issue is particularly important in lmic settings, where it may not be affordable for mental health specialists (psychiatrists, psychologists) to administer diagnostic instruments (saraceno, ; barbui et al., ). the gap between the individuals in need of mental health interventions and those who actually receive such care remains very large (world health organization, ) . a study of countries with the who mental health surveys found that . % of persons with depressive disorder in lmics received any treatment in the past months, and only . % of persons with depressive disorder received minimally adequate treatment (thornicroft et al., ) . furthermore, the quality of care received by many people, in particular those affected by severe mental disorders and disabilities, was poor in all countries and was often associated with abuses of their fundamental human rights (patel et al., ) . this is despite the existence of a range of cost-effective interventions in mental health care in lmics (tol et al., ; van ginneken et al., ; purgato et al., a purgato et al., , b barbui et al., ) . major barriers to closing the treatment gap are the huge persistent scarcity of skilled human resources, large inequities and inefficiencies in resource distribution and utilisation, limited community awareness of mental health, poverty and social deprivation, and the significant stigma associated with psychiatric illness (barber et al., ) . some papers have advocated for scaling up evidence-based services and for the task-shifting of mental health interventions to non-specialists as key strategies for closing the treatment gap (patel et al., ) . moreover, the world health organization (who) developed the mental health gap action programme intervention guide (mhgap-ig) through a systematic review of evidence followed by an international participatory consultative process. the mhgap-ig comprises straightforward, user-friendly, diagnosis-specific clinical guidelines for providing evidence-based practices for non-specialised health care providers. the mhgap may be adapted for national and local needs, and consider the task-shifting approaches a promising strategy for improving mental health care delivery (world health organization, ) . task-shifting entails the shifting of tasks, typically from more to less highly trained individuals to make efficient use of these resources, allowing all providers to work at the top of their scope of practice. this includes primary care health workers (phws) and community workers (cws). phws are first-level health providers who have received general health training rather than specialist mental health training and can be based in a primary care clinic or in the community. cadres included are professionals (doctors, nurses and other general paraprofessionals) and non-professionals (such as trained lay health providers). phws do not include, for example, psychiatrists, psychologists, psychiatric nurses or mental health social workers. cws such as teachers and community-level workers who have no background health training, but who may perform a particular mental health function within their role, are a further human resource employed in delivering promotion, prevention and treatment interventions . the differences in the organisation of mental health services between lmics and high-income countries (hics), with poorer countries having little or no mental health service structures in primary care or the community, means that the problem of providing mental health care is different in such settings. pws may need to work with little or no support from specialist mental health services and fewer options for referral. consequently, pws interventions might be expected to function differently in many lmics compared with hics. in lmics, phws and cws have been employed in various services, including those delivered by governmental, private and non-governmental organisations in clinics, half-way homes, schools and communities. for example, lay health workers have been involved in supporting carers, befriending, ensuring adherence and delivering simple mental health interventions . nurses, social workers and cws may also take on follow-up or educational/promotional roles (araya et al., ; chatterjee et al., ; chatterjee et al., ) . in addition, doctors with general mental health training have been involved in the identification, diagnosis, treatment and referral of complex cases . teachers and other educational support staff have been an important resource for child mental health care (dybdahl, ; gordon et al., ; shen et al., ) and for the delivery of prevention interventions (ager et al., ) . the task-shifting approach is being used across a wide range of mental conditions in lmics and has increasing evidence of being effective (van ginneken et al., update in progress) , though still only a small percentage of psychological interventions in lmics actually include nonspecialists as providers (fig. ) . promotion is an approach aimed at strengthening positive aspects of mental health and psychosocial wellbeing, and is focused on empowering people to live healthy lives (e.g. by facilitating healthy lifestyles through policies, such as providing nutritious foods in school canteens or opportunities for physical exercise in accessible locations), rather than health being the sole domain of health professionals (national research council and institute of medicine, ). it includesfor examplecomponents to foster pro-social behaviour, self-esteem, coping, decision-making capacity, but also universal interventions such as social and economic interventions to improve people's social determinants of health which would impact on their wellbeing. prevention is an approach aimed at reducing the likelihood of future disorder in the general population or for people who are identified as being at risk of a disorder (eaton, ; tol et al., ) . prevention is further subdivided on the basis of the population targeted, into universal, selective and indicated (national research council and institute of medicine, ). universal prevention, which includes strategies that can be offered to the whole population including individuals who are not at risk, based on the evidence that it is likely to provide some benefit to all (reduce the probability of disorder), clearly outweighs the costs and risks of negative consequences. examples of common universal prevention interventions include the community-wide provision of information on positive coping methods (iasc, ) to help people feeling safe and hopeful, protection against human rights violations (e.g. gender-based violence), community-wide efforts to improve livelihoods as a key protective factor for mental health. selective prevention refers to strategies that are targeted to subpopulations identified as being at elevated biological, social or psychological risk for a disorder but who are asymptomatic or have very minimal symptoms. these interventions involve human, supportive and practical help covering both a social and a psychological dimension. they work through communication (asking about people needs and concerns; listening to people and helping them to feel calm), practical support (i.e. providing meals or water) and with a psychological approach including teaching stress management skills and helping people to cope with problems (world health organization, ); facilitation of community support for vulnerable individuals by activating social networks and communication; structured cultural and recreational activities supporting the development of resilience (national research council and institute of medicine, ), such as traditional dancing, art work, sports and puppetry. these activities may take place in equipped settings with the aim of increasing the children's sense of connectivity and safety (tol et al., ) . indicated prevention includes strategies that are targeted to individuals who are identified (or individually screened) as having detectable signs or symptoms which can foreshadow, precede and may sometimesif left unaddressedlead to a full diagnosable mental disorder based on an individual assessment. these interventions to prevent mental disorders may be delivered at individual or group level, in a variety of settings (antenatal and postnatal visits, home visits, community settings, schools, etc.). these interventions include psychosocial support for persons with subclinical levels of mental disorders (purgato et al., a) , such as mentoring programmes aimed at children with behavioural problems; psychological first aid for people with heightened levels of psychological distress after exposure to severe stressors, loss or bereavement (tol et al., ) . this includes facilitator-guided self-help group interventions, as for example the who self-help plus (epping-jordan et al., ; purgato et al., a) . unlike hics, in lmics, factors as the socioecology of poverty, malnutrition, political conflicts, lack or poor implementation of mental health policy, poor governance in mental health and health systems, and lower priority for mental health influence the epidemiology, outcomes and treatment strategies of mental health problems (yasamy et al., ; baingana et al., ) . treatment interventions are delivered to people who have a diagnosed mental disorder. however, sometimes, these treatment interventions, particularly psychological or psychosocial interventions, are also considered as effective treatments for those population groups that may receive 'indicated prevention' interventions in the category above. from the lancet commission on global mental health (which reconceptualised mental illness symptoms along a transdiagnostic staged spectrum), there is some evidence that treatments for mental disorders can overlap and be as effective for those with prodromal symptoms as for those with a diagnosable mental disorder (patel et al., ) . treatment interventions include various forms of psychotherapy and/or pharmacological treatment. in addition, treatment interventions may include broader interventions sometimes delivered by phws or cws (and sometimes by specialist psychiatric nurses) such as training in self-help interventions, informal support, transdiagnostic psychosocial support (individualised plan addressing social and emotional functioning and problems) and high-risk individual identification which may be particularly relevant to those who have detectable subthreshold signs and symptoms of mental illness (van ginneken et al., ) . long-term interventions are important to help rehabilitate people after acute mental disorders, maintain stable mental health for those with chronic mental disorders and prevent recurrence or relapse. these could include roles in follow-up or rehabilitation of people with chronic severe mental disorders, and roles in detecting and dealing with relapse/recurrence, compliance issues, treatment resistance, side effects of treatment or psychosocial problems (patel et al., ) . these may be individual or combined interventions, delivered either as a simple contained group of sessions, or as a complex collaborative care provision following a stepped care protocol or a shared care between primary care and specialist care (van ginneken et al., ; barbui et al., ) . despite the conceptual similarities and growing evidence for mental health promotion, prevention and treatment interventions may share conceptual similarities across the world and have growing evidence, delivering these interventions in lmics is bound with several challenges. the acceptability of interventions might also be different, especially as for distressed participants who do not present an established psychiatric diagnosis dealing with their psychological distress may not be a high priority as dealing with other social or health issues. participants (and their families) with a mental disorder, by contrast, may recognise that dealing with psychological problems is a high priority and a pre-requisite for optimal social functioning, thus showing more compliance and participation in psychological interventions. many lmics either lack or are poor in implementation of mental health policies, programmes and interventions and have difficult access to mental health care (alloh et al., ) . a key factor attributing to mental health issues in lmics is the discrimination against people suffering from mental illnesses where often they are labelled, exempted and even abused (alloh et al., ) . henceforth, people in lmics are often reluctant to seek mental healthcare services to avoid the circumstances where they are socially discriminated. the condition is further aggravated in many lmics where people identified with mental health problems experience stigma even during treatment, which in turn leads to poor care, delay in seeking health services or nonadherence to treatments (alloh et al., ) . 'for an instance, it is a very common myth that people suffering from mental illness rarely get recovered in south western nigeria' (orngu, ) . additionally, the coordination and management of mental health interventions in humanitarian settings including conflicts, disasters, epidemic and pandemic may present major challenges. for example, despite an increase in the incidence of mental health problems during armed conflicts, earthquakes, epidemics and famine in countries like nepal, haiti and ethiopia, the limited resources are diverted to areas other than mental health (rathod et al., ) . there may also be many different socio-economic factors which influence the burden of mental health. in many lmics, social factors such as poverty, gender, urbanisation, internal migration and lifestyle changes are moderators of the magnitude of mental health problems (rathod et al., ; wainberg et al., ) . furthermore, low levels of knowledge regarding mental health problems have been suggested as an important factor that delays the interventions' onset (henderson et al., ) . finally, the resources for delivery and training, and the types of cadres of health workers involved increase heterogeneity across interventions, which become difficult to compare. training, supervision and competency assessment of those delivering these interventions have also traditionally not been priorities in lmic due to scarce human and financial resources (though these have become increasingly addressed features of lmic trials) marianna purgato et al. (kakuma et al., ) and limited dissemination and implementation research capacity (wainberg et al., ) . despite research in global mental health rapidly growing, with rigorous studies implemented in lmic settings, there remain several research challenges to be addressed. mental ill health is globally recognised as one of the major public health problems yet mental health care and promotion/prevention are less prioritised in many lmics (alloh et al., ) . furthermore, there are various difficulties that are faced by mental health researchers in lmics including lack of good mental health research governance, lack of funding, shortage of trained personnel to carry out mental health research, unequal distribution of mental health research capacity, difficulty in training due to weaker institutional infrastructure, constraints on investigators' time owing to healthcare delivery and teaching responsibilities, absence of a strong research 'culture', poor peer networks and collaborations (the academy of medical sciences, ; yasamy et al., ) . moreover, there are other practical problems and context-dependent issues that hinder mental health research in lmics. for example, low mental health literacy among the larger research community and frequent migration make large-scale intervention trials and prospective studies a challenge (yasamy et al., ) . given the magnitude of the burden of mental disorders, although treatment intervention alone will not be enough to close the mental health gap in lmics, mental health promotion and prevention of mental illness are at an incipient stage in most lmics (wainberg et al., ) . although difficult to achieve in lmics, decreasing structural inequality, stigma and social discrimination is an important prevention intervention targeted towards mental illnesses. current evidence is insufficient to determine what prevention interventions are effective and feasible for decreasing stigma in lmics, how best to target key groups such as health care staff, and how to adapt such interventions in specific contexts (wainberg et al., ) . one of the complexities with research interventions delivered in lmics is that asymptomatic, prodromal and/or disordered populations overlap within the same experimental study. there is variation in the categorising of interventions and/or population groups as belonging to the treatment or various prevention categories. in practical terms, it means that experimental studies may include participants showing no distress, some psychological distress and/or participants with a formal psychiatric diagnosis. this is due often to not having the setting, tools, manpower or not felt appropriate to select people based on screening tools, but rather based on situational settings a much more immediate and tangible inclusion criterion particularly in difficult settings like war-torn or highly deprived settings. mixed population groups are thus likely to increase heterogeneity, as the clinical response and compliance to interventions may vary. in this scenario, subgroup analyses based on participant symptom stage may be a strategy to evaluate interventions' efficacy. the 'grey area' between treatment and prevention, i.e. the indicated prevention, is often difficult to categorise as their aims can be to either treat participants to reduce their symptoms or help them recover, or to prevent the development of mental disorder. whilst categorising these interventions to decide which of the parallel systematic reviews on treatment and prevention interventions (both ongoing) they would fit in, we divided these studies according to these expected aims and outcomes. studies where the intervention aim was to achieve recovery or symptom improvement were included in the treatment review (van ginneken et al., update in progress) . those aimed at preventing mental disorders went into the prevention review . several studies were difficult to discern and needed to be included in both reviews due to uncertainty of mixed populations. once these reviews are completed we may be able to produce more specific guidance on whether this strategy worked and how. furthermore, the choice of control group is relevant for research in lmics and may have clinical implications. in many lmics, participants suffer from long-lasting and even chronic conditions because they lack the possibility of receiving appropriate evidence-based treatments (purgato et al., b) . despite the waiting list as a control condition has been criticised because of limiting participants seeking care for their mental condition elsewhere because they are waiting for the intervention (cuijpers and cristea, ; cuijpers et al., ) , this is less of a concern in many lmics, in which often the alternative is simply not receiving care at all. even the control group defined as treatment as usual (tau) may vary according to populations and contexts, to the point that being in the tau condition sometimes corresponds to not getting treatments at all and differentiating tau from no treatment or from waiting list control might become difficult. we do not intend to provide a conclusive or simplistic framework for categorizing mental health interventions in lmics. however, clarifying key concepts of relevance to public mental health and how it is intertwined with task-shifting to expand universal access, may help both researchers and practitioners in the design, assessment and implementation of evidence-based interventions. financial support. none. conflict of interest. none. the impact of the school-based psychosocial structured activities (pssa) program on conflict-affected children in northern uganda mental health in low-and middle income countries (lmics): going beyond the need for funding treating depression in primary care in low-income women in global research challenges and opportunities for mental health and substance-use disorders microaggressions towards people affected by mental health problems: a scoping 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countries challenges and opportunities in global mental health: a research-to-practice perspective global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health gap action programme (mhgap) intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health gap action programme (mhgap) world health organization, war trauma foundation, and world vision international ( ) psychological first aid: guide for field workers responsible governance for mental health research in low resource countries key: cord- - jzkdu authors: bickman, leonard title: improving mental health services: a -year journey from randomized experiments to artificial intelligence and precision mental health date: - - journal: adm policy ment health doi: . /s - - - sha: doc_id: cord_uid: jzkdu this conceptual paper describes the current state of mental health services, identifies critical problems, and suggests how to solve them. i focus on the potential contributions of artificial intelligence and precision mental health to improving mental health services. toward that end, i draw upon my own research, which has changed over the last half century, to highlight the need to transform the way we conduct mental health services research. i identify exemplars from the emerging literature on artificial intelligence and precision approaches to treatment in which there is an attempt to personalize or fit the treatment to the client in order to produce more effective interventions. in , i was writing my first graduate paper at columbia university on curing schizophrenia using sarnoff mednick's learning theory. i was not very modest even as a first-year graduate student! but i was puzzled as to how to develop and evaluate a cure. then, as now, the predominant research design was the randomized experiment or randomized clinical trial (rct). it was clear that simply describing, let alone manipulating, the relevant characteristics of this one disorder and promising treatments would require hundreds of variables. developing an effective treatment would take what seemed to me an incalculable number of randomized trials. how could we complete all the randomized experiments needed? how many different outcomes should we measure? how could we learn to improve treatment? how should we consider individual differences in these group comparisons? i am sure i was not insightful enough to think of all these questions back then, but i know i felt frustrated and stymied by our methodological approach to answering these questions. but i had to finish the paper, so i relegated these and similar questions to the list of universal imponderables such as why i exist. in fact, i became a committed experimentalist, and i dealt with the limitations of experiments by recognizing their restrictions and abiding by the principle "for determining causality, in many but not all circumstances, the randomized design is the worst form of design except all the others that have been tried " (bickman and reich , pp. - ) . for the much of my career, i was a committed proponent of the rct as the best approach to understanding causal relationships (bickman ) . however, as some of my writing indicates, it was a commitment with reservations. i did not see a plausible alternative or complement to rcts until recently, when i began to read about artificial intelligence (ai) and precision medicine in . the potential solution to my quandary did not crystallize until , when i collaborated with aaron lyons and miranda wolpert on a paper on what we called "precision mental health" (bickman et al. ) . with the development of ai and its application in precision medicine, i now believe that ai is another approach that we may be able to use to understand, predict, and influence human behavior. while not necessarily a substitute for rcts in efforts to improve mental health services, i believe that ai provides an exciting alternative to rcts or an adjunct to them. while i use precision medicine and precision mental health interchangeably, i will differentiate them later in this paper. toward that end, i focus much of this paper on the role of ai and precision medicine as a critical movement in the field with great potential to inform the next generation of research. before proposing such solutions, i first describe the challenges currently faced by mental health services, using examples drawn almost entirely from studies of children and youth, the area in which i have conducted most of my research. i describe five principal causes of this failure, which i attribute primarily, but not solely, to methodological limitations of rcts. lastly, i make the case for why i think ai and the parallel movement of precision medicine embody approaches that are needed to augment, but probably not replace, our current research and development efforts in the field of mental health services. i then discuss how ai and precision mental health can help inform the path forward, with a focus on similar problems manifested in mental health services for adults. these problems, i believe, make it clear that we need to consider alternatives to our predominant research approach to improving services. importantly, most of the research on ai and precision medicine i cite deals with adults, as there is little research in this area on children and youth. i am assuming that we can generalize from one literature to the other, but i anticipate that there many exceptions to this assumption. according to some estimates, more than half ( . %) of adults with a mental illness receive no treatment (mental health in america ) . less than half of adolescents with psychiatric disorders receive any kind of treatment (costello et al. ) . over % of youth with major depression do not receive any mental health treatment (mental health in america ). several other relevant facts when it comes to youth illustrate the problem of their access to services. hodgkinson et al. ( ) have documented that less than % of children in poverty receive needed services. these authors also showed that there is less access to services for minorities and rural families. when it comes to the educational system, mental health in america ( ) estimated that less than % of students have an individual education plan (iep), which students need to access school-supported services, even though studies have shown that a much larger percentage of students need those services. access is even more severely limited in in low-and middle-income countries (esponda et al. ). very few clients receive effective evidence-based quality mental health services that have been shown to be effective in laboratory-based research (garland et al. ; gyani et al. ). moreover, research shows that even when they do receive care that is labeled evidence-based, it is not implemented with sufficient fidelity to be considered evidence-based (park et al. ) . no matter how effective evidence-based treatments are in the laboratory, it is very clear that they lose much of their effectiveness when implemented in the real world (weisz et al. (weisz et al. , . research reviews demonstrate that services that are typically provided outside the laboratory lack substantial evidence of effectiveness. there are two factors that account for this lack of effectiveness. as noted above, evidencebased services are usually not implemented with sufficient fidelity to replicate the effectiveness found in the laboratory. more fundamentally, it is argued here that even evidencebased services may not be sufficiently effective as currently conceptualized. a review of published studies on school-based health centers found that while these services increased access, the review could not determine whether services were effective because the research was of such poor quality (bains and diallo ) . a meta-analysis of studies of mental health interventions implemented by school personnel found small to medium effect sizes, but only % of the services were provided by school counselors or mental health workers (sanchez et al. ) . a cochrane review concluded, "we do not know whether psychological therapy, antidepressant medication or a combination of the two is most effective to treat depressive disorders in children and adolescents" (cox et al. , p. ) . another meta-analysis of studies on school-based interventions delivered by teachers showed a small effect for internalizing behaviors but no effect on externalizing ones (franklin et al. a) . similarly, a meta-analysis of meta-analyses of universal prevention programs targeting school-age youth showed a great deal of variability with effect sizes from to . standard deviations depending on type of program and targeted outcome (tanner-smith et al. ) . a review of rcts found no compelling evidence to support any one psychosocial treatment over another for people with serious mental illnesses (hunt et al. ) . a systematic review and meta-analysis of conduct disorder interventions concluded that they have a small positive effect, but there was no evidence of any differential effectiveness by type of treatment (bakker et al. ) . fonagy and allison ( ) conclude, "the demand for a reboot of psychological therapies is unequivocal simply because of the disappointing lack of progress in the outcomes achieved by the best evidence-based interventions" (p. ). probably the most discouraging evidence was identified by weisz et al. ( ) on the basis of a review of rcts over a -year period. they found that the mean effect size for treatment did not improve significantly for anxiety and adhd and decreased significantly for depression and conduct problems. the authors conclude: in sum, there were strikingly few exceptions to the general pattern that treatment effects were either unchanged or declining across the decades for each of the target problems. one possible implication is that the research strategy used over the past decades, the treatment approaches investigated, or both, may not be ideal for generating incremental benefit over time. (p. ) there is a need-indeed, an urgent need-to change course, because our traditional approaches to services appear not to be working. however, we might be expecting too much from therapy. in an innovative approach to examining the effectiveness of psychotherapy for youth, jones et al. ( ) subjected rcts to a mathematical simulation model that estimated that even if therapy was perfectly implemented, the effect size would be a modest . . they concluded that improving the quality of existing psychotherapy will not result in much better outcomes. they also noted that ai may help us understand why some therapies are more effective than others. they suggested that the impact of therapy is limited because a plethora of other factors influence mental health, especially given that therapy typically lasts only one hour a week out of + waking hours. they also indicated that other factors that have not been included in typical therapies, such as individualizing or personalizing treatment, may increase the effectiveness of treatment. i am not alone in signaling concern about the state of mental health services. for example, other respected scholars in children's services research have also raised concerns about the quality and effectiveness of children's services. weisz and his colleagues (marchette and weisz ; ng and weisz ) described several factors that contribute to the problems identified above. these included a mismatch between empirically supported treatments and mental health care in the real world, the lack of personalized interventions, and the absence of transdiagnostic treatment approaches. it is important to acknowledge the pioneering work of sales and her colleagues, who identified the need and tested approaches to individualizing assessment and monitoring clients (alves et al. (alves et al. , elliott et al. ; alves , ; sales et al. sales et al. , . we need not only to appreciate the relevance of this work but also to integrate it with new artificial intelligence approaches described later in this paper. i am not concluding from such evidence that all mental health services are ineffective. this brief summary of the state of our services can be perceived in terms of a glass half full or half empty. in other words, there is good evidence that some services are effective under particular, but yet unspecified, conditions. however, i do not believe that the level of effectiveness is sufficient. moreover, we are not getting better at improving service effectiveness by following our traditional approach to program development, implementation, research, and program evaluation. while it is unlikely that the social and behavioral sciences will experience a major breakthrough in discovering how to "cure" mental illness, similar to those often found in the physical or biological sciences, i am arguing in this paper that we must increase our research efforts using alternative approaches to produce more effective services. a large part of this paper, therefore, is devoted to exploring what has been also called a precision approach to treatment in which there is an attempt to personalize treatment or fit treatment to the client in order to produce more effective interventions. in some of my earliest work in mental health, i identified the field's focus on system-level factors rather than on treatment effectiveness as one cause of the problems with mental health services. the most popular and well-funded approach to mental health services in the s and s, which continues even today, is called a system or continuum of care (bickman (bickman , bickman et al. b; bryant and bickman ) . this approach correctly recognized the problems with the practice of providing services that were limited to outpatient and hospitalization only, which was very common at that time. moreover, these traditional services did not recognize the importance of the role played by youth and families in the delivery of mental services. to remedy these important problems, advocates for children's mental health conceptualized that a system of care was needed, in which a key ingredient was a managed continuum of care with different levels or intensiveness of services to better meet the needs of children and youth (stroul and friedman ) . this continuum of care is a key component of a system of care. however, i believe that in actuality, these different levels of care simply represent different locations of treatment and restrictiveness (e.g., inpatient vs. outpatient care) and did not necessarily reflect a gradation of intensity of treatment. a system of care is not a specific type of program, but an approach or philosophy that combines a wide range of services and supports for these services with a set of guiding principles and core values. services and supports are supposed to be provided within these core values, which include the importance of services that are community-based, family-focused, youth-oriented, in the least restrictive environment, and culturally and linguistically proficient. system-level interventions focus on access and coordination of services and organizations and not on the effectiveness of the treatments that are provided. it appeared that the advocates of systems of care assumed that services were effective and that what was needed was to organize them better at the systems level. although proponents of systems of care indicated that they highly valued individualized treatment, especially in what were called wraparound services, there was no distinct and systematic way that individualization was operationalized or evaluated. moreover, there was not sufficient evidence that supported the assumption that wraparound services produced better clinical outcomes (bickman et al. ; stambaugh et al. ) . a key component of the system is providing different levels of care that include hospitalization, group homes, and outpatient services, but there is little evidence that clinicians can reliably assign children to what they consider the appropriate level of care (bickman et al. a ). my earliest effort in mental health services research was based on a chance encounter that led to the largest study ever conducted in the field of child and youth mental health services. i was asked by a friend to see if i could help a person whom i did not know to plan an evaluation of a new way to deliver services. this led to a project that cost about $ million to implement and evaluate. we evaluated a new system of care that was being implemented at fort bragg, a major u.s. army post in north carolina. we used a quasi-experimental design because the army would not allow us to conduct a rct; however, we were able to control for many variables by using two similar army posts as controls (bickman ; bickman et al. ) . the availability of sufficient resources allowed me to measure aspects of the program that were not commonly measured at that time, such as cost and family empowerment. with additional funding that i received from a competitive grant from the national institute of mental health (nimh) and additional follow-up funding from the army, we were able to do a cost-effectiveness analysis (foster and bickman ) , measure family outcomes (heflinger and bickman ) , and develop a new battery of mental health symptoms and functioning (bickman and athay ). in addition, we competed successfully for an additional nimh grant to evaluate another system of care in a civilian population using a rct (bickman et al. a, b) and a study of a wraparound services that was methodologically limited because of sponsor restrictions (bickman et al. ) . i concluded from this massive and concentrated effort that systems of care (including the continuum of care) were able to influence system-level variables, such as access, cost, and coordination, but that there was not sufficient evidence to support the conclusion that it produced better mental health outcomes for children or families or that it reduced costs per client . this conclusion was not accepted by the advocates for systems of care or the mental health provider community more generally. moreover, i became persona non grata among the proponents of systems of care. while the methodologists who were asked to critique on the fort bragg study saw it as an important but not flawless study (e.g., sechrest and walsh ; weisz et al. ) that should lead to new research (hoagwood ) , most advocates thought it to be a well-done evaluation but of very limited generalizability (behar ). it is important to note that the system of care approach, almost years later, remains the major child and youth program funded by the substance abuse and mental health services administration's (samhsa) center for mental health services (cmhs) to the tune of about a billion dollars in funding since the system of care program's inception in . there have been many evaluations funded as part of the samhsa program that show some positive results (e.g., holden et al. ), but, in my opinion, they are methodologically weak and, in some cases, not clearly independent. systems of care are still considered by samhsa's center for mental health services to be the premier child and adolescent program worthy of widespread diffusion and funding (substance abuse and mental health services administration ), regardless of what i believe is the weak scientific support. this large investment of capital should be considered a significant opportunity cost that has siphoned off funds and attention from more basic concerns such as effectiveness of services. sadly, based on my unsuccessful efforts to encourage change as a member of the cmhs national advisory council ( - ), i am not optimistic that there will be any modification of support for this program or shift of funding to more critical issues that are identified in this paper. in the following section, i consider some of the problems that have contributed to the current status of mental health services. my assessment of current services led me to categorize the previously described deficiencies into the five following related problem groups. the problems with the validity of diagnoses have existed for as long as we have had systems of diagnoses. while a diagnosis provides some basis for tying treatment to individual case characteristics, its major contribution is providing a payment system for reimbursement for services. research has shown that external factors such as insurance influence the diagnosis given, and the diagnosis located in electronic health records is influenced by commercial interests (perkins et al. ; taitsman et al. ) . other studies have demonstrated that the diagnosis of depression alone is not sufficient for treatment selection; additional information is required (iniesta et al. ). moreover, others have shown that diagnostic categories overlap and are not mutually exclusive (bickman et al. c) . in practice, medication is prescribed according to symptoms and not diagnosis (waszczuk et al. ) . in their thematic analysis of selected chapters of the diagnostic and statistical manual of mental disorders (dsm- ), allsopp et al. ( ) examined the heterogeneous nature of categories within the dsm- . they showed how this heterogeneity is expressed across diagnostic criteria, and explained its consequences for clinicians, clients, and the diagnostic model. the authors concluded that "a pragmatic approach to psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way of understanding distress than maintaining commitment to a disingenuous categorical system" (p. ). moreover, in an interview, allsop stated: although diagnostic labels create the illusion of an explanation, they are scientifically meaningless and can create stigma and prejudice. i hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences. (neuroscience news , para. ) finally, a putative solution to this muddle is nimh's research domain criteria initiative (rdoc) diagnostic guide. rdoc is not designed to be a replacement of current systems but serves as a research tool for guiding research on mental disorders systems. however, it has been criticized on several grounds. for example, heckers ( ) states, "it is not clear how the new domains of the rdoc matrix map on to the current dimensions of psychopathology" (p. ). moreover, there is limited evidence that rdoc has actually improved the development of treatments for children (e.g., clarkson et al. ) . as i will discuss later in the paper, rush and ibrahim ( ) , in their critical review of psychiatric diagnosis, predicted that ai, especially artificial neural networks, will change the nature of diagnosis to support precision medicine. if measures are going to be used in real world practice, then in addition to the classic and modern psychometric validity criteria, it must be possible to use measures sufficiently often to provide a fine-grained picture of change. if measures are used frequently, then they must be short so as not to take up clinical time (riemer et al. ) . moreover, since there is a low correlation among different respondents (de los reyes and ohannessian ), we need measures and data from different respondents including parents, clinicians, clients, and others (e.g., teachers). however, we are still lacking a systematic methodology for managing these different perspectives. since we are still unsure which constructs are important to measure, we need measures of several different constructs in order to pinpoint which ones we should administer on a regular basis. in addition to outcome measures, we need valid and reliable indicators of mediators and processes to test theories of treatment as well as to indicate short-term outcomes. we need measures that are sensitive to change to be valid measures of improvement. we need new types of measures that are more contextual, that occur outside of therapy sessions, and that are not just standardized questionnaires. we lack good measures of fidelity of implementation that capture in an efficient manner what clinicians actually do in therapy sessions. this information is required to provide critical feedback to clinicians. we also lack biomarkers of mental illness that can be used to develop and evaluate treatments that are often found in physical illnesses. this is a long and incomplete list of needs and meeting them will be difficult to accomplish without a concerted effort. there are some resources at the national institutes of health that are focused on measure development, such as patient-reported outcomes measurement system information (promis) (https ://www.healt hmeas ures.net/explo re-measu remen t-syste ms/promi s), but this program does not focus on mental health. thus, we depend upon the slow and uncoordinated piecemeal efforts of individual researchers to somehow fit measure development into their career paths. i know this intimately because when i started to be engaged with children's mental health services research, i found that the measures in use were too long, too expensive, and far from agile. this dissatisfaction led me down a long path to the development of a battery of measures called the peabody treatment progress battery riemer et al. ). this battery of brief measures was developed as part of ongoing research grants and not with any specific external support. for over a half century, i have been a committed experimentalist. i still am a big fan of experiments for some purposes (bickman ). the first independent study i conducted was my honors thesis at city college of new york in . my professor was a parapsychologist and personality psychologist, so the subject of my thesis was extrasensory perception (esp). my honors advisor had developed a theory of esp that predicted that those who were positive about esp, whom she called sheep, would be better at esp than the people who rejected esp, whom she called goats (schmeidler ) . although i did not realize it at the time, my experimentalist or action orientation was not satisfied with correlational findings that were the core of the personality approach. i designed an experiment in which i randomly assigned college students to hear a scripted talk from me supporting or debunking esp. i found very powerful results. the experimental manipulation changed people's perspective on the efficacy of esp, but i found no effect on actual esp scores. it was not until i finished my master's degree in experimental psychopathology at columbia university that i realized that i wanted to be an experimental social psychologist, and i became a graduate student at the city university of new york. however, i did not accept the predominant approach of social psychologists, which was laboratory experimentation. i was convinced that research needed to take place in the real world. although my dissertation was a laboratory study of helping behavior in an emergency , it was the last lab study i did that was not also paired with a field experiment (e.g. bickman and rosenbaum ) . one of my first published research studies as a graduate student was a widely cited field experiment (rct) that examined compliance to men in different uniforms in everyday settings (bickman a, b) . the first book i coedited, as a graduate student, was titled beyond the laboratory: field research in social psychology and was composed primarily of field experiments (bickman and henchy ) . almost all my early work as a social psychologist consisted of field experiments . i strongly supported the primacy of randomized designs in several textbooks i coauthored or coedited (alasuutari et al. ; bickman and rog ; bickman and rog ; hedrick et al. ) . while the fort bragg study i described above was a quasi-experiment (bickman ) , i was not happy that the funding agency, the u.s. army, did not permit me to use a rct for evaluating an important policy issue. as i was truly committed to using a rct to evaluate systems of care, i followed up this study with a conceptual replication in a civilian community using a rct (bickman et al. b ) that was funded by a nimh grant. while i have valued the rct and continue to do so, i have come to the conclusion that our experimental methods were developed for simpler problems. mental health research is more like weather forecasting with thousands of variables rather than like traditional experimentation, which is based on a century-old model for evaluating agricultural experiments with only a few variables (hall ) . we need alternatives to the traditional way of doing research, service development, and service delivery that recognize the complexity of disorders, heterogeneity of clients, and varied contexts of mental health services. the oversimplification of rcts has produced a blunt tool that has not served us well for swiftly improving our services. this is not to say that there has been no change in the last years. for example, the institute of education sciences, a more recent player the field of children's behavioral and mental health outcomes research, has released an informative monograph on the use of adaptive randomized trials that does demonstrate flexibility in describing how rcts can be implemented in innovative ways (nahum-shani and almirall ). the concerns about rcts are also apparent in other fields. for example, a special issue of social science and medicine focused on the limitations of rcts (deaton and cartwright ) . the contributors to this incisive issue indicated that a rct does not in practice equalize treatment and control groups. rcts do not deliver precise estimates of average treatment effects (ates) because a rct is typically just one trial, and precision depends on numerous trials. there is also an external validity problem; that is, it is difficult to generalize from rcts, especially those done in university laboratory settings. context is critical and theory confirmation/disconfirmation is important, for without generalizability, the findings are difficult to apply in the real world (bickman et al. ) . scaling up from a rigorous rct to a community-based treatment is now recognized as a significant problem in the relatively new fields of translational research and implementation sciences. in addition to scaling up, there is a major issue in scaling down to the individual client level. stratification and theory help, but they are still at the group level. the classic inferential approach also has problems with replication, clinical meaningfulness, accurate application to individuals, and p-value testing (dwyer et al. ) . the primary clinical problem with rcts is the emphasis on average treatment effects (ates) versus individual prediction. rcts emphasize postdiction, and ates lead to necessary oversimplification and a focus on group differences and not individuals. subramanian et al. ( ) gave two examples of the fallacy of averages: the first was a study to describe the "ideal woman," where they measured nine body dimensions and then averaged each one. a contest to identity the "average woman" got responses, but not a single woman matched the averages on all nine variables. in a second example, the u.s. air force in measured pilots on body dimensions to determine appropriate specifications for a cockpit. not a single pilot matched the averages on even as few as dimensions, even when their measurements fell within % of the mean value. as these examples show, the problem with using averages has been known for a long time, but we have tended to ignore this problem. we are disappointed when clinicians do not use our research findings when in fact our findings may not be very useful for clinicians because clinicians deal with individual clients and not some hypothetical average client. we can obtain significant differences in averages between groups, but the persons who actually benefit from therapy will vary widely to the extent to which they respond to the recommended treatments. thus, the usefulness of our results depends in part on the heterogeneity of the clients and the variability of the findings. the privileging of rcts also came with additional baggage. instead of trying to use generalizable samples of participants, the methodology favored the reduction of heterogeneity as a way to increase the probability of finding statistically significant results. this often resulted in the exclusion from studies of whole groups of people, such as women, children, people of color, and persons with more than one diagnosis. while discussions often included an acknowledgment of this limitation, little was done about these artificial limitations until inclusion of certain groups was required by federal funding agencies (national institutes of health, central resource for grants and funding information ) . the limitations of rcts are not a secret, but we tend to ignore these limitations (kent et al. ) . one attempt to solve the difficulty of translating average effect sizes by rcts to individualize predictions is called reference class forecasting. here, the investigator attempts to make predictions for individuals based on "similar" persons treated with alternative therapies. however, it is rarely the case that everyone in a clinical trial is influenced by the treatment in the same way. an attempt to reduce this heterogeneity of treatment effects (hte) by using conventional subgroup analysis with one variable at a time is rejected by kent et al. ( ) . they argue that this approach does not work. first, there are many variables on which participants can differ, and there is no way to produce the number of groups that represent these differences. for example, matching on just binary variables would produce over a million groups. moreover, one would have to start with an enormous sample to maintain adequate statistical power. the authors describe several technical reasons for not recommending this approach to dealing with the hte problem. they also suggested two other statistical approaches, risk modeling and treatment effect modeling, that may be useful, but more research on both is needed to support their use. kent et al. ( ) briefly discussed using observational or non-rct data, but they pointed out the typical problems of missing data and other data quality issues as well as the difficulty in making causal attributions. moreover, they reiterated their support for the rct as the "gold standard." although published in , their article mentioned machine learning only as a question for future research-a question that i address later in this paper. i will also present other statistical approaches to solving the limitations of rcts. there is another problem in depending upon rcts as the gold standard. nadin ( ) pointed out that failed reproducibility occurs almost exclusively in life sciences, in contrast to the physical sciences. i would add that the behavioral sciences have not been immune from criticisms about replicability. the open science collaboration ( ) systematically sampled results from three top-tier journals in psychology, and only % of the replication efforts yielded significant findings. this issue is far from resolved, and it is much more complex than simple replication (laraway et al. ) . nadin ( ) considered the issue of the replicability as evidence of an underlying false assumption about treating humans as if they were mechanistic physical objects and not reactive human beings. he noted that physics is nomothetic, while biology is idiographic, meaning that the former is the study of the formulation of universal laws and the latter deals with the study of individual cases or events. without accurate feedback, there is little learning (kluger and denisi ) . clinicians are in a low feedback occupation, and unlike carpenters or surgeons, they are unlikely to get direct accurate feedback on the effects of their activities. when carpenters cut something too short, they can quickly see that it no longer fits and have to start with a new piece, so they typically follow the maxim of measure twice, cut once. because clinicians in the real world of treatment do not get direct accurate feedback on client outcomes, especially after clients leave treatment, then they are unlikely to learn how to become more effective clinicians from practice alone. clinical practice is thus similar to an archer's trying to improve while practicing blindfolded (bickman ) . moreover, the services research field does not learn from treatment as usual in the real world, where most treatment occurs, because very few services collect outcome data, let alone try to tie these data to clinician actions (bickman b) . there are two critical requirements needed for learning. the first is the collection of fine-grained data that are contemporaneous with treatment. the second is the feedback of these data to the clinician or others so that they can learn from these data. learning can be accomplished with routine use of measures such as patient outcome measures (poms) and feedback through progress monitoring, measurementbased care (mbc), and measurement feedback systems (mfs). these measurement feedback concepts have repeatedly demonstrated their ability to improve outcomes in therapy across treatment type and patient populations (brattland et al. ; bickman et al. ; dyer et al. ; gibbons ; gondek et al. ; lambert et al. ) . despite this evidence base, most clinicians do not use these measurement feedback systems. for example, in one of the largest surveys of canadian psychologists, only % were using a progress monitoring measure (ionita et al. ) . a canadian psychological association task force (tasca et al. ) reinforced the need for psychologists to systematically monitor and evaluate their services using continuous monitoring and feedback. they stated that the association should encourage regulatory bodies to prioritize training in their continuing education and quality assurance requirements. moreover, lewis et al., in their review of measurement-based care ( ), presented a -point research agenda that captures much the ideas in the present paper: ( ) harmonize terminology and specify mbc's core components; ( ) develop criterion standard methods for monitoring fidelity and reporting quality of implementation; ( ) develop algorithms for mbc to guide psychotherapy; ( ) test putative mechanisms of change, particularly for psychotherapy; ( ) develop brief and psychometrically strong measures for use in combination; ( ) assess the critical timing of administration needed to optimize patient outcomes; ( ) streamline measurement feedback systems to include only key ingredients and enhance electronic health record interoperability; ( ) identify discrete strategies to support implementation; ( ) make evidence-based policy decisions; and ( ) align reimbursement structures. (p. ) it is not surprising that the measurement feedback approach has not yet produced dramatic effects, given how little we know about what data to collect, how often it should be collected, what feedback should be, and when and how it should be provided (bickman et al. ) . regardless, every time a client is treated, it is an opportunity to learn how to be more effective. by not collecting and analyzing information from usual care settings, we are missing a major opportunity to learn from ordinary services. the most successful model i know of using this real-world services approach is the treatment of childhood cancers in hospitals where most children enter a treatment rct (o'leary et al. ) . these authors note that in the past years, the survival rates for childhood cancer have climbed from % to almost %. they attribute this remarkable improvement to clinical research through pediatric cooperative groups. this level of cooperation is not easy to develop, and it is not frequently found in mental health services. most previous research shows differential outcomes among different types of therapies that are minor at most (wampold and imel ) . for example, weisz et al. ( ) report that in their meta-analysis, the effect of treatment type as a moderator was not statistically significant but there was a significant, but not clearly understood, treatment type by informant interaction effect. in addition, the evidence that therapists have a major influence on the outcomes of psychotherapy is still being hotly debated. the fact that the efficacy of therapists is far from a settled issue is troubling (anderson et al. ; goodyear et al. ; hill et al. ; king and bickman ) . also, current drug treatment choices in psychiatry are successful in only about % of the patients (bzdok and meyer-lindenberg ) and are as low as - % for antidepressants (dwyer et al. ) . while antidepressants are more effective than placebos, they have small effect sizes (perlis ) , and the choice of specific medicine is a matter of trial and error in many cases. it is relatively easy to distinguish one type of drug from another but not so for services, where even dosage in psychosocial treatments is hard to define. according to dwyer et al. ( ) , "currently, there are no objective, personalized methods to choose among multiple options when tailoring optimal psychotherapeutic and pharmacological treatment" (p. ). a recent summary concluded that after years and studies, it is unknown which patients benefit from interpersonal psychotherapy (ipt) versus another treatment (bernecker et al. ) . however, to provide a more definitive answer to the question about which treatments are more effective, we need head-to-head direct comparisons between different treatments and network meta-analytic approaches such as those used by dagnea et al. ( ) . the field of mental health is not alone in finding that many popular medications do not work with most of the people who take them. nexium, a common drug for treating heartburn, works with only person out of , while crestor, used to treat high cholesterol, works with only out of (schork ) . this poor alignment between what the patient needs, and the treatment provided is the primary basis for calling for a more precise medicine approach. this lack of precision leads to the application of treatments to people who cannot benefit from it, thus leading to overall poor effectiveness. in summary, a deep and growing body of work has led me to conclude that we need additional viable approaches to a rct when it comes to conducting services-related research. an absence of rigorous evaluation of treatments that are usually provided in the community contributes to a gap in our understanding why treatments are ineffective (bickman b) . poor use of measurement in routine care (bickman ) and the absence of measurement feedback systems and clinician training and supervision (garland et al. ) are rampant. there also a dire need for the application of more advanced analytics and data mining techniques in the mental health services area (bickman et al. ). these and other such challenges have in turn informed my current thinking about alternative or ancillary approaches for addressing the multitude of problems plaguing the field of mental health services. the five problems i have described above constitute significant obstacles to achieving accessibility, efficiency, and effectiveness in mental health services. nevertheless, there is a path forward that i believe can help us reach these goals. artificial intelligence promises to transform the way healthcare is delivered. the core of my recommendations in this paper rests on the revolutionary possibilities of artificial intelligence for improving mental healthcare through precision medicine that allows us to take into account the individual variability that exists with respect to genetic and other biological, environmental, and lifestyle characteristics. several others have similarly signaled a need for considering the use of personalized approaches to service delivery. for example, weisz and his colleagues (marchette and weisz ; ng and weisz ) called for more idiographic research and for studies tailoring strategies in usual care. kazdin ( ) focused on expanding mental health services through novel models of intervention delivery; called for task shifting among providers; advocated designing and implementing treatments that are more feasible, using disruptive technologies, for example, smartphones, social media such as twitter and facebook, and socially assistive robots; and emphasized social network interventions to connect with similar people. ai is currently used in areas ranging from prediction of weather patterns to manufacturing, logistic planning to determine efficient delivery routes, banking, and stock trading. ai is used in smartphones, cars, planes, and the digital assistants siri and alexa. in healthcare, decision support, testing and diagnosis, and self-care also use ai. ai can sort through large data sets and uncover relationships that humans cannot perceive. through learning that occurs with repeated, rapid use, ai surpasses the abilities of humans only in some areas. however, i would caution potential users that there are significant limitations associated with ai that are discussed later in this paper. rudin and carlson ( ) present a non-technical and well written review of how to utilize ai and of some of the problems that are typically encountered. ai is not one type of program or algorithm. machine learning (ml), a major type of ai, is the construction of algorithms that can learn from and make predictions based on data. it can be ( ) supervised, in which the outcome is known and labeled by humans and the algorithm learns to get that outcome; ( ) unsupervised, when the program learns from data to predict specific outcomes likely to come from the patterns identified; and ( ) reinforcement learning, in which ml is trial and error. in most cases, there is an extensive training data set that the algorithm "learns" from, followed by an independent validation sample that tests the validity of the algorithm. other variations of ai include random forest, decision trees, and the support vector machine (svm), a multivariate supervised learning technique that classifies individuals into groups (dwyer et al. ; shrivastava et al. ). the latter is most widely used in psychology and psychiatry. artificial neural networks (anns) or "neural networks" (nns) are learning algorithms that are conceptuality related to biological neural networks. this approach can have many hidden layers. deep learning is a special type of machine learning. it helps to build learning algorithms that can function conceptually in a way similar to the functioning of the human brain. large amounts of data are required to use deep learning. ibm's watson won jeopardy with deepqa algorithms designed for question answering. as exemplified by the term neural networks, algorithm developers appear to name their different approaches with reference to some biological process. genetic algorithms are based on the biological process of gene propagation and the methods of natural selection, and they try to mimic the process of natural evolution at the genotype level. it has been a widely used approach since the s. natural language processing (nlp) involves speech recognition, natural language understanding, and natural language generation. nlp may be especially useful in analyzing recordings of a therapy session or a therapist's notes. affective computing or sentiment analysis involves the emotion recognition, modeling, and expression of emotion by robots or chatbots. sentiment analysis can recognize and respond to human emotions. virtual reality and augmented reality are human-computer interfaces that allow a user to become immersed within and interact with computer-generated simulated environments. hinton ( ) , a major contributor to research on ai and health, described ai as the use of algorithms and software to approximate human cognition in the analysis of complex data without being explicitly programmed. the primary aim of health-related ai applications is to analyze relationships between prevention or treatment techniques and patient outcomes. ai programs have been developed and applied to practices such as diagnosis processes, treatment protocol development, drug development, personalized medicine, and patient monitoring and care. deep learning is best at modeling very complicated relationships between input and outputs and all their interactions, and it sometimes requires a very large number of cases-in the thousands or tens of thousands-to learn. however, there appears to be no consensus about how to determine, a priori, the number of cases needed, because the number is highly dependent on the nature of the problem and the characteristics of the data. ai is already widely used in medicine. for example, in ophthalmology, photos of the eyes of persons with diabetes were screened with % specificity and % sensitivity in detecting diabetes (gargeya and leng ) . one of the more prolific uses of ai is in the diagnosis of skin cancer. in a study that scanned , clinical images, the ai approach had accuracy similar to that of board-certified dermatologists (esteva et al. ) . cardiovascular risk prediction with ml is significantly improved over established methods of risk prediction (krittanawong et al. ; weng et al. ). however, a study by desai et al. ( ) found only limited improvements in predicting heart failure over traditional logistic regression. in cancer diagnostics, ai identified malignant tumors with % accuracy compared to % accuracy for human pathologists (liu et al. ). the ibm's watson ai platform took only min to analyze a genome of a patient with brain cancer and suggest a treatment plan, while human experts took h (wrzeszczynski et al. ) . ai has also been used to develop personalized immunotherapy for cancer treatment (kiyotani et al. ). rajpurkar et al. ( ) compared chest x-rays for signs of pneumonia using a state-of-the-art -layer convolutional neural network (cnn) program with a "swarm" of radiologists (groups connected by swarm algorithms) and found the latter to be significantly more accurate. in a direct comparison between radiologists on , interpretations and a stand-alone deep learning ai program designed to detect breast cancer in mammography, the ai program was as accurate as the radiologists (rodriguez-ruiz et al. ). as topol ( b) noted, ai is not always the winner in comparison with human experts. moreover, many of these applications have not been used in the real world, so we do not know how well ai will scale up in practice. topol describes other concerns with ai, many of which are discussed later in this paper. finally, many of the applications are visual, such as pictures of skin or scans, for which ai is particularly well suited. large banks of pictures often form the training and testing data for this approach. in mental health, visual data are not currently as relevant. however, there is starting to be some research on facial expressions in diagnosing mental illness. for example, abdullah and choudhury ( ) cite several studies that showed that patients with schizophrenia tend to show reduced facial expressivity or that facial features can be used to indicate mental health status. more generally, there is research showing how facial expressions can be used to indicate stress (mayo and heilig ) . visual data are ripe for exploration using ai. although an exhaustive review of the ai literature and its applications is well beyond the focus of this paper, rudin and carlson ( ) present a well-written, non-technical review of how to utilize ai and of some of the problems that are typically encountered. topol ( a) , in his book titled deep medicine: how artificial intelligence can make healthcare human again, includes a chapter on how to use of ai in mental health. topol ( b) also provides an excellent review of ai and its application to health and mental health in a briefer format. buskirk et al. ( ) and y. liu et al. ( ) provide well-written and relatively brief introductions to ml's basic concepts and methods and how they are evaluated. a more detailed introduction to deep learning and neural networks is provided by minar and naher ( ) . in most cases, i will use the generic term ai to refer to all types of ai unless the specific type of ai (e.g., ml for machine learning, dl for deep learning, and dnn for deep neural networks) is specified. precision medicine has been defined as the customization of healthcare, with medical decisions, treatments, practices, or products being tailored to the individual patient (love-koh et al. ) . typically, diagnostic testing is used for selecting the appropriate and best therapies based a person's genetic makeup or other analysis. in an idealized scenario, a person may be monitored with hundreds of inputs from various sources that use ai to make predictions. the hope is that precision medicine will replace annual doctor visits and their granular risk factors with individualized profiles and continuous longitudinal health monitoring (gambhir et al. ) . the aim of precision medicine, as stated by president barack obama when announcing his precision medicine initiative, is to find the long-sought goal of "delivering the right treatments, at the right time, every time to the right person" (kaiser ) . both ai and precision medicine can be considered revolutionary in the delivery of healthcare, since they enable us to move from one-size-fits-all diagnoses and treatment to individualized diagnoses and treatments that are based on vast amounts of data collected in healthcare settings. the use of ai and precision medicine to guide clinicians will change diagnoses and treatments in significant ways that will go beyond our dependence on the traditional rct. precision medicine should also be seen as evolutionary since even hippocrates advocated personalizing medicine (kohler ) . the importance of a precision medicine approach was recognized in the field of prevention science with a special issue of prevention science devoted to that topic (august and gewirtz ) . the articles in this special issue recognize the importance of identifying moderators of treatment that predict heterogeneous responses to treatment. describing moderators is a key feature of precision medicine. once these variables are discovered, it becomes possible to develop decision support systems that assist the provider (or even do the treatment assignment) in selecting the most appropriate treatment for each individual. this general approach has been tried using a sequential multiple assignment randomized trial (smart) in which participants are randomized two to three times at key decision points (august et al. ) . what i find notable about this special issue is the absence of any focus on ai. the articles were based on a conference in october , and apparently the relevance of ai had not yet influenced these very creative and thoughtful researchers at that point. precision medicine does not have an easy path to follow. x. liu et al. ( b) describe several challenges, including the following three. large parts of the human genome are not well enough known to support analyses; for example, almost % of our genetic code is unknown. it is also clear that a successful precision medicine approach depends on having access to large amounts of data at multiple levels, from the genetic to the behavioral. moreover, these data would have be placed into libraries that allow access for researchers. the u.s. federal government has a goal of establishing such a library with data on one million people through nih's all of us research program (https ://allof us.nih.gov/). recruitment of volunteers who would be willing to provide data and the "harmonization" of data from many different sources are major issues. x. liu et al. ( b) also point to ethical issues that confront precision medicine, such as informed consent, privacy, and predictions that someone may develop a disease. these issues are discussed later in this paper. chanfreau-coffinier et al. ( ) provided a helpful illustration of how precision medicine could be implemented. they convened a conference of veterans affairs stakeholders to develop a detailed logic model that can be used by an organization planning to introduce precision medicine. this model includes components typically found in logic models, such as inputs (clinical and information technology), big data (analytics, data sources), resources (workforce, funding) activities (research), outcomes (healthcare utilization), and impacts (access). the paper also includes challenges to implementing precision medicine (e.g., a poorly trained workforce) that apply to mental health. ai has the potential to unscramble traditional and new diagnostic categories based on analysis of biological/genetic and psychological data, and in addition, more data will likely be generated now that the potential for analysis has become so much greater. ai also has the potential to pinpoint those individuals who have the highest probability of benefiting from specific treatments and to provide early indicators of success or failure of treatment. research is currently being undertaken to provide feedback to clinicians at key decision points as an early warning of relapse. fernandes et al. ( ) describe what the authors call the domains related to precision psychiatry (see fig. ). these domains include many approaches and techniques, such as panomics, neuroimaging, cognition, and clinical characteristics, that form several domains including big data and molecular biosignature; the latter includes biomarkers. the authors include data from electronic health records, but i would also include data collected from treatment or therapy sessions as well as data collected outside of these sessions. these domains can be analyzed using biological and computational tools to produce a biosignature, a higher order domain that includes data from all the lower level techniques and approaches. this set of biomarkers in the biosignature should result in improved diagnosis, classification, and prognosis, as well as individualized interventions. the authors note that this bottom-up approach, from specific approaches to domains to the ultimate biosignature, can also be revised to a top-down approach, with the biosignature studied to better understand domains and its specific components. the bottom of the figure shows a paradigm shift where precision psychiatry contributes to different treatments being applied to persons with different diagnoses and endophenotypes, producing different prognoses. endophenotypes is a term used in genetic epidemiology to separate different behavioral another perspective on precision psychiatry is presented by bzdock and meyer-lindberg ( ). both models contain similar concepts. both start with a group of persons containing multiple traditional diagnoses. bzdock and meyer-lindberg recognize that these psychiatric diagnoses are often artificial dichotomies. machine learning is applied to diverse data from many sources and extracts hidden relationships. this produces different subgroups of endophenotypes. machine learning is also used to produce predictive models of the effects of different treatments instead of the more typical trial and error. further refinement of the predictive ml models results in better treatment selection and better prediction of the disease trajectory. an excellent overview of deep neural networks (dnns) in psychiatry and its applications is provided by durstewitz et al. ( ) . in addition to explaining how dnns work, they provide some suggestions on how dnns can be used in clinical practice with smartphones and large data sets. a major feature of deep neural networks is their ability to learn and adapt with experience. while dnns typically outperform ml, the authors state that they do not fully understand why this is the case. in mental health, dnns have been mostly used in diagnosis and predictions but not in designing personalized treatments. dnn's ability to integrate many different data sets (e.g., various neuroimaging data, movement patterns, social media, and genomics) should provide important insights on how to personalize treatments. regardless of the model used, eyre et al. ( ) remind us that consumers should not be left out of the development of precision psychiatry. in my conceptualization of precision medicine, precision mental health encompasses precision psychiatry and any other precision approach such as social work that focuses on mental health (bickman et al. ). there has not been much written about using a precision approach with psychosocial mental health services. possibly it is psychiatry's close relationship to general medicine and its roots in biology that make psychiatry more amenable to the precision science approach. in addition, the use of the precision construct is being applied in other fields, as exemplified by the special issue of the journal of school psychology devoted to precision education (cook et al. ) and precision public health (kee and taylor-robinson ) . however, in this paper i am primarily addressing the use of psychosocial treatment of mental health problems, which differs in important ways from psychiatric treatment. for example, precision psychosocial mental health treatment does not have a strong biological/medical perspective and does not focus almost exclusively on medication; instead, it emphasizes psychosocial interventions. psychosocial mental health services are also provided in hospital settings, but their primary use is in community-based services. these differences lead to different data sources for ai analyses. it is highly unlikely that electronic mental healthcare records found outside of hospital settings contain biological and genomic data (serretti ) . but hospital records are not likely to contain the detailed treatment process data that could possibly be found in community settings. the genomic and biological data offer new perspectives but may not be informative until we have a better understanding about the genomic basis of mental illness. in addition, the internet of things and smart healthcare connect wearable and home-based sensors that can be used to monitor movement, heart rate, ecg, emg, oxygen level, sleep, and blood glucose, through wi-fi, bluetooth, and related technologies. (sundaravadivel et al. ) . with wider use of very fast g internet service, there will be a major increase in the growth of the internet of things. i want to emphasize that applying precision medicine concepts to mental health services, especially psychotherapy, is a very difficult undertaking. the data requirements for psychosocial mental health treatment are more similar to meteorology or weather forecasting than to agriculture, which is considered the origin of the rct design. people's affect, cognition, and behavior are constantly changing just like the variables that affect weather. but unlike meteorology, which is mainly descriptive and not yet engaged in interventions, mental health services are interventions. thus, in addition to client data, we must identify the variables that are critical to the success of the intervention. we are beginning to grasp how difficult this task is as we develop greater understanding that the mere labeling of different forms of treatment by location (e.g., hospital or outpatient) or by generic type (e.g., cognitive behavior therapy) is not sufficiently informative. moreover, the emergence of implementation sciences has forced us to face the fact that a treatment manual describes only some aspects of the treatments as intended but does not describe the treatment that is actually delivered. nlp is a step in the right direction in trying to capture some aspects of treatment as actually delivered. data quality is the foundation upon which ai systems are built. while medical records are of higher technical quality than community-based data because they must adhere to national standards, i believe that the nascent interest in measurement-based care and measurement feedback systems in community settings bodes well for improved data systems in the future. moreover, although electronic hospitalbased data may be high quality from a technical viewpoint (validity, reliability) and be very large, they probably do not contain the data that are valuable for developing and evaluating mental health services. the development of electronic computer-based data collection and feedback systems will become more common as the growth in ai demands large amounts of good-quality treatment and finer grained longitudinal outcome data. there is a potential reciprocal relationship between the ai needs for large, high-quality data sets and the development of new measurement approaches and the electronic systems needed to collect such data (bickman a; bickman et al. a bickman et al. , . to accomplish this with sufficiently unbiased and valid data will be a challenge. ai can bypass many definitional problems by not using established diagnostic systems. ml can use a range of variables to describe the individual ml classifier systems (tandon and tandon ) . moreover, additional sources of data that help in classification are now feasible. for example, automated analysis of social media including tweets and facebook can detect depression, with accuracy measured by area under the curve (auc) ranging from . to . compared to clinical interviews with aucs of . (guntuku et al. ). as noted earlier, dnns have been shown to be superior to other machine learning approaches in general and specifically in identifying psychiatric stressors for suicide from social media (du et al. ). predictions of , adolescent suicides with ml showed high accuracy (auc > . ) and outperformed traditional logistic regression analyses ( . - . aucs) (tandon and tandon ) . saxe has published a pioneering proof of concept that has demonstrated that ml methods can be used to predict child posttraumatic stress (saxe et al. ) . ml was more accurate than humans in predicting social and occupational disability with persons in high-risk states of psychosis or with recent-onset depression (koutsouleris et al. a) . machine learning has also been used in predicting psychosis using everyday language (rezaii et al. ) . another application of ai to diagnosis is provided by kasthurirathne et al. ( ) . they demonstrated the ability to automate screening for , adult patients in need of advanced care for depression using structured and unstructured data sets covering acute and chronic conditions, patient demographics, behaviors, and past service use history. the use of many existing data elements is a key feature and thus does not depend on single screening instruments. the authors used this information to accurately predict the need for advanced care for depression using random forest classification ml. milne et al. ( ) recognized that in implementing online peer counseling, professionals need to participate and/or provide safety monitoring in using ai. however, cost and scalability issues appeared to be insurmountable barriers. what is needed is an automated triage system that would direct human moderators to cases that require the most urgent attention. the triage system milne et al. developed sent human moderators color-coded messages about their need to intervene. the algorithm supporting this triage system was based on supervised ml. the accuracy of the system was evaluated by comparing a test set of manually prioritized messages with the ones developed through the algorithm. they used several methods to judge accuracy, but their main one was an f-measure, or the harmonic mean of recall (i.e., sensitivity) and precision (i.e., positive predictive value). regression analysis indicated that the triage system made a significant and unique contribution to reducing the time taken to respond to some messages, after accounting for moderator and community activity. i can see the potential for this and similar ai approaches to deal with the typical service setting where some degree of supervision is required but even intermittent supervision is not feasible or possible. another use of ml as a classification tool is provided by pigoni et al. ( ) . in their review of treatment resistant depression, they found that ml could be used successfully to classify responders from non-responders. this suggested that stratification of patients might help in selecting the appropriate treatment, thus avoiding giving patients treatments that are unlikely to work with them. a more general systematic review and meta-analysis of the use of ml to predict depression are provided by lee et al. ( ) . the authors found qualitative and quantitative studies that qualified for inclusion in their review. while most of the studies were retrospective, they did find predictions with an average overall accuracy of . . kaur and sharma ( ) reviewed the literature on diagnosis of ten different psychological disorders and examined the different data mining and software approaches (ai) used in different publications. depending on the disorder and the software used, the accuracy ranged from to %. accuracy was defined differently depending on the study. only % of the articles exploring diagnosis of any health problem were found to be for psychological problems. this suggests that we need more studies on diagnosis and ai. a very informative synthesis and review are provided by low et al. ( ) . they screened studies and reviewed the that met the inclusion criterion: studies from the last years using speech to identify the presence or severity of disorders through ml methods. they concluded that ml could be predictive, but confidence in any conclusions was dampened by the general lack of cross-validation procedures. the article contains very useful information on how best to collect and analyze speech samples. another innovative approach using ml focused on wearable motion detector sensors, in which these devices were worn for s during a -s mood induction task (seeing a fake snake). these data were able to distinguish children with an internalizing disorder from controls with % accuracy (mcginnis et al. ) . this approach has potential for screening children for this disorder. a problem that seemingly has been ignored by most studies that deal with classification or diagnosis is the gold standard by which accuracy is judged. in most cases, the gold standard is human judgment, which is especially fallible when it comes to mental health diagnosis. we can clearly measure whether the ai approach is faster and less expensive than human judgment, but is the ultimate in ai accuracy matching human judgment with all its flaws? i believe that the endpoint that must also be measured is client clinical mental health improvement. a system that provides faster and less expensive diagnosis but does not lead to more precise treatment and better clinical outcomes will save us time and money, which are important, but they will not be the breakthrough for which we are looking. a solution to the problems described above will involve the integration of causal discovery methods with ai approaches. ai methods are capable of improving our capacity to predict outcomes. to enhance predictability, we will need to identify the factors in the predictive models that are causal. thus, there is the need to identify techniques that provide us with causal knowledge, which currently is based primarily on rcts. but, for real-world and ethical reasons, human etiological experiments can rarely be conducted. fortunately, there are newer ai methods that can be used to infer causes, which include well validated tests of conditional independencies based on the causal markov condition (pearl ; aliferis et al. ; saxe ) . these methods have been successfully used outside of psychiatry (sachs et al. ; ramsey et al. ; statnikov et al. ) and have, in the last five years, been applied in research on mental health, largely by the team of glenn saxe at new york university and constantin aliferis and sisi ma at university of minnesota. this group has reported causal models of ptsd in hospitalized injured children (saxe et al. (saxe et al. , , children seen in outpatient trauma centers (saxe et al. ) , maltreated children (morales et al. ) , adults seen in emergency rooms (galatzer-levy et al. ) , and police officers who were exposed to trauma (saxe et al. in press ). saxe ( ) recently described the promise of these methods for psychiatric diagnosis and personalized precision medicine. new measures need to be developed that cover multiple domains of mental health, are reported by different respondents (e.g., child, parent, clinician), and are very brief. cohen ( ) provides an excellent overview of what he calls ambulatory biobehavioral technologies in a special section of psychological assessment. he notes that the development of mobile devices can have a major impact on psychological assessment. he cautions, however, that while some of these approaches have been used for decades, they still have not progressed beyond the proof of concept phase for clinical and commercial applications. ecological momentary assessment (ema) is a relatively new approach to measurement development. ema is the collection of real-time data collected in naturalistic environments. this approach uses a wide range of smart watches, bands, garments, and patches with embedded sensors (gharani et al. ; pistorius ) . for example, using smartphones, researchers have identified gait features for estimating blood alcohol content level (gharani et al. ). other researchers have been able to map changes in emotional state ranging from sad to happy by using a movement sensor on smart watches (quiroz et al. ) . others have described real-time fluctuations in suicidal ideation and its risk factors, using an average of . assessments per day (kleiman et al. ) . social anxiety has been assessed from global positioning data obtained from smart watches by noting that socially anxious students were found to avoid public places and to spend more time at home than in leisure activities outside the home (boukhechba et al. ) . a review of studies using ema concluded that the compliance rate was moderate but not optimal and could be affected by study design (wen et al. ). this review is also a good source of descriptions of different approaches to using ema. another good summary that focused on ema in the treatment of psychotic disorders can be found in bell et al. ( ) . for ema use in depression and anxiety, schueller et al. ( ) is a good source. ema has been used to measure cardiorespiratory function, movement patterns, sweat analysis, tissue oxygenation, sleep, and emotional state (peake et al. ) . harari et al. ( ) present a catalog of behavior in more than aspects of daily living that can be used in studying physical movement, social interactions, and daily activities. these include walking, speaking, text messaging, and so on. these all can be collected from smartphones and serve as an alternative to traditional survey approaches. however, it is still not clear what higher-level constructs are measured using these approaches. a comprehensive and in-depth review of studies that have used speech to assess psychiatric disorders is provided by low et al. ( ) . they conclude that speech processing technology could assist in mental health assessments but believe that there are many obstacles to this use, including the need for longitudinal studies. another interesting application for children is the use of inexpensive screening for internalizing disorders. mcginnis et al. ( ) monitored the child's motion for s using a commercially available and inexpensive wearable sensor. using a supervised ml approach, they obtained an % accuracy ( % sensitivity, % specificity) compared to similar clinical threshold on parent-reported child symptoms that differentiate children with an internalizing diagnosis from controls without such a diagnosis. in a systematic review of ema use in major depression, colombo et al. ( ) evaluated studies that met their criteria for inclusion. these studies measured a wide variety of variables including self-reported symptoms, sleep patterns, social contacts, cortisol, heart rate, and affect. they point out many of the advantages of using emas such as realtime assessments, capturing the dynamic nature of change, improving generalizability, and providing information about context. they believe that the use of emas has resulted in novel insights about the nature of depression. they do note that there are few evaluations of these measures, and there is not much use in actual clinical practice. mohr et al. ( ) note that most of the research on ema has been carried out primarily by computer scientists and engineers using a very different research model than social and behavioral scientists. while computer scientists are mostly interested in exploratory proof of concepts approach (does it work at all?) using very small samples, social/behavioral scientists are more typically theory driven and investigate under what conditions the intervention will work. mental health care, apart from medication, is almost exclusively verbal. several approaches have been tried to capture the content of treatment sessions. my colleagues and i have tried by asking clinicians to use a brief checklist of topics discussed after each therapy session . although this technique produced some interesting findings such as the identification of topics that the clinician did not discuss but that were believed to be important by the youth or parent, it is clearly filtered by what the clinician recalls and is willing to check off as having been discussed. while recordings provide a richer source of information, coding recordings manually is too expensive and slow for the real world of service delivery. the content of therapy sessions, including notes kept by clinicians, is pretty much ignored by researchers because of the difficulty and cost of manually coding those sources. however, advances in natural language processing (nlp) are now being explored as a way of capturing aspects of the content of therapy sessions. for example, tanana et al. ( ) have shown how two types of nlp techniques can be used to study and code the use of motivational interviewing in taped sessions. carcone et al. ( ) also showed that they could accurately code motivational interviewing (mi) clinical encounter transcripts with sufficient accuracy. other researchers have used ai to analyze speech to distinguish between what they called high-and low-quality counselors (pérez-rosas et al. ). some colleagues and i have submitted a proposal to nimh to refine nlp tools that can be used to supervise clinicians implementing an evidence-based treatment using ai. as far as we know, using nlp to measure fidelity and provide feedback to clinicians has not been studied in a systematic way. while ai appears to be an attractive approach to new ways of analyzing data, it should be noted that, as always, the quality of the analysis is highly dependent on the quality of the data. jacobucci and grimm ( ) caution us that "in psychology specifically, the impact of machine learning has not been commensurate with what one would expect given the complexity of algorithms and their ability to capture nonlinear and interactive effects" (p. ). one observation made by these authors is that the apparent lack of progress in using ai may be caused by "throwing the same set of poorly measured variables that have been analyzed previously into machine learning algorithms" (p. ). they note that this is more than the generic garbage in, garbage out problem, but it is specifically related to measurement error, which can be measured relatively accurately. as described earlier, our privileging of rcts has contributed to a lack of focus on a precision approach to mental health services. this has resulted in the problem of ignoring the clinical need for predicting for an individual in contrast to establishing group difference, the approach favored by the experimentalist/ hypothesis testing tradition. ai offers an approach to the discovery of important relationships in mental health in addition to rcts that are based on singlesubject prediction accuracy and not null hypothesis testing (bzdok and karrer ) . saxe et al. ( ) have demonstrated the use of the complex-systems-causal network method to detect causal relationships among variables and bivariate relations in a psychiatric study using algorithms. a comprehensive review and meta-analysis of machine learning algorithms that predict outcomes of depression showed excellent accuracy ( . ) using multiple forms of data (lee et al. ) . it is interesting to note that none of the scholars commenting on the rct special issue in social science and medicine (deaton and cartwright ) specifically mentioned the use of ai as a potential solution to some of the problems of using average treatment effects (ates). kessler et al. ( a) noted that clinical trials do not tell us which treatments are more effective for which patients. they suggested that what they label as precision treatment rules (ptrs) be developed that are predictors of the relative treatment effectiveness of different treatments. the authors presented a comprehensive discussion on how to use ml to develop ptrs. they concluded that the sample sizes needed are much larger than usually those found in rcts; observational data, especially from electronic medical records (emrs) can be used to deal with the sample size issue; and statistical methods can be used to balance both observed and unobserved covariates using instrumental variables and discontinuity designs. they do note the difficulty in obtaining full baseline data from emrs and suggest several solutions for this problem, including supplemental data collection and links to other archival sources. they recommend the use of an ensemble ml approach that combines several algorithms. they are clear that their suggestions are exploratory and require verification, but they are more certain that if ml improves patient outcomes, it will be a substantial improvement. wu et al. ( ) collaborated with kessler on a proof of concept of a similar model called individualized treatment rules (itr). in a model simulation, they used a large sample (n = , ) with an ensemble ml method to identify the advantages of using ml algorithms to estimate the outcomes if a precision medicine approach was taken in prescribing medication for persons with first-onset schizophrenia. they found that the treatment success was estimated to be . % under itr compared to . % with the medication that was actually used. wu et al. see this as a first step that needs to be confirmed by pragmatic rcts. kessler et al. ( b) conducted a relatively small randomized study (n = ) in which soldiers seeking treatment were judged to be at risk for suicide. they were randomly assigned to two types of treatment but not on the basis of any a priori ptr. the data from that study were then analyzed using ml to produce ptrs. these data were then modeled in a simulation to see if the ptr would have produced better outcomes. the authors did find that the simulated ptr produced better effects. lenze et al. ( ) address the problems of rcts from a somewhat different perspective than i have presented here and suggest a potential solution that they call precision clinical trials (pcts). the authors propose that the problem with most existing rcts is that they measure only the fixed baseline characteristics that are not usually sensitive to detecting treatment responders. moreover, treatment is typically not dynamically adapting to the client during treatment, and measures are not administered with sufficient frequency. instead, the pcts would: ( ) first attempt to determine whether short-term responses to the intervention could determine who was a likely candidate for that specific treatment; ( ) initiate the treatment in an adaptive fashion that could vary over time, using stepped care or just-in-time adaptations that are responsive to the client's changing status, and frequently collect data possibly using multiple assignment randomized trial methods; and ( ) use frequent precision measurement, possibly using ecological momentary assessments described earlier. coincidently, they illustrate the application of pcts using repetitive transcranial magnetic stimulation (rtms), a form of brain stimulation therapy used to treat depression and anxiety that has been in use since . rtms will be described later in connection with what i call a third path for services and ai. it is disappointing that i could not find any examples of published research that used a rct to test whether an ai approach to an actual, not simulated, delivery of a mental health treatment produces better clinical outcomes than a competitive treatment or even treatment as usual. this is clearly an area requiring further rigorous empirical investigation. imel et al. ( ) provide an excellent overview on how ai and other technologies can be used for monitoring and feedback in psychotherapy in both training and supervision. imel et al. ( ) used ml to code and provide data to clinicians on metrics used to measure the quality of motivational interviewing (mi). a prior study (tanana et al. ) established that ml was able to code mi quality metrics with accuracy similar to human coders. they conducted a pilot study using standardized patients and -min speech segments that was designed to test the feasibility of providing feedback to clinicians on the quality of their mi intervention. the feedback was not in real-time but was provided after the session. they were able to establish that clinicians thought highly of the feedback they received. the authors anticipate that further developments in this technology will lead to its widespread use in supervision and in real-time feedback. it would seem that the next step is evaluating the enhanced ai feedback procedure in a real-world effectiveness study. another example of the use of nlp application is the use of a bot that was trained to assess and provide feedback on specific interviewing and counseling skills such as asking open-ended questions and providing feedback (tanana et al. ) . after training the bot on transcripts, non-therapists (using amazon mechanical turk recruits) were randomly assigned to either immediate feedback on a practice session with the bot or just encouragement on the use of those skills. the group provided the feedback were significantly more likely to use reflection even when feedback was removed. the authors consider this to be a proof of concept demonstration because of the many limitations (e.g., use of non-therapists). a plan for using nlp to monitor and provide feedback to clinicians on the implementation of an evidenced program is provided by berkel et al. ( ) . they provide excellent justification for using nlp to accomplish this goal, but unfortunately it is only a design at this point. rosenfeld et al. ( ) see ai making major contributions to improving the quality of treatment through efficient continuous monitoring of patients. until now, monitoring was limited to in-session contacts or manual contacts, an approach that is not practical or efficient. the almost universal availability of smartphones and other internet active devices (internet of things) makes collecting data from clients practical and efficient. these various data sources provide feedback to providers so that they can predict and prevent relapse and compliance with treatment, especially medication. the authors note that there is not a large body of research in this area, but early studies are positive. one concrete application of ai to providing feedback is described by ryan and his colleagues . their article only describes how such could be done; unfortunately, it is not an actual study but a suggestion on how to apply ai for feedback to physicians to improve their communications with patients. they note that routine assessment and feedback are not done manually because of the cost and time requirements. however, ai can automate these tasks by evaluating recordings. they suggest using already existing ai approaches that are in use by call centers to categorize and evaluate communication along the following dimensions: speaker ratio that indicates listening, overlapping talk that are interruptions, pauses longer than two seconds, speed, pitch, and tone. the content could also be evaluated along the dimensions of the use of plain language, clinical jargon, and shared decision making. ai could also explore other dimensions such as the meaning of words and phrases using nlp, turn taking, tone, and style. many technical difficulties would have to be overcome to assess many of these variables, but the field is making progress. an actual application of ml to feedback, but not in mental health, is provided by pardo et al. ( ) in a course for first-year engineering students. instructors developed in advance a set of feedback messages for levels of interaction with learning resources. for example, different feedback messages were provided depending on whether the student barely looked at video, watched a major portion, watched the whole video, or watched it several times. an ml algorithm selected the appropriate message to send the student through either email or the virtual learning environment. compared to earlier cohorts who did not receive the feedback, those who did were more satisfied with the course and had better performance on the midterm. i can see how such a protocol could be used in mental health services. an indication of the work that needs to be done in becoming more specific about feedback is a study conducted by hooke et al. ( ) . they provide feedback to patients with and without a trajectory showing expected progress and found that patients preferred the feedback with the expected change over time. they found that these patients preferred to have normative feedback with which they could compare their own ideographic progress. two systematic reviews that focused on implementing routine outcome measurement (rom) concluded that while rom has been shown to produce positive results, how to best implement rom remains to be determined by future research (gual-montolio et al. ; mackrill and sorensen ) . the authors of both reviews note several interesting points but focus on these two: how to integrate measurement into clinical practice and how organizations support staff in this effort. they highlight the importance of developing a culture of feedback in organizations. neither review includes any studies using ai. while they call for more research to move this field forward, i do not think there will be much change until either measurement feedback systems are required by funders or service delivery organizations are paid for providing such systems. probably the most advanced work in this area that includes ml is being done by lutz and his colleagues (lutz et al. ) . they have developed a measurement feedback system that includes the use of ml to make predictions and to provide clinicians with clinical decision support tools. they are able to predict dropouts and assign support tools to clinicians that are specific to the problems their clients are exhibiting, based on the data they have collected. lutz and his colleagues are currently evaluating the system to influence clinical outcomes in a prospective study. this comprehensive feedback system provided clinical support tools with recommendations based on identification of similar patients to the treatment group but not to the control group. they already have some very promising results using three different treatment strategies (w. lutz, personal communication, september , ) . almost all the research in this area has been on prediction and not in actually testing whether precision treatments are in fact better than standard treatments in improving mental health outcomes. even these predictive studies are on extant databases rather than data collected specially for use in ai algorithms. with a few exceptions to be discussed later, this is the state of the art. to establish the practical usefulness of ai, we need to move beyond prediction to show actual mental health improvements that have clinical and not just statistical significance. there are some scholars who are carefully considering how to improve methodology to achieve better predictions (e.g., garb and wood ) . in addition, zilcha-mano ( ) has a very thoughtful paper that describes traditional statistical and machine learning approaches to trying to answer the core question of what treatments work best for which patients, as well as the more general question about why psychotherapy works at all. nlp has been used to analyze unstructured or textual material for identifying suicidal ideation in a psychiatric research database. precision of % for identification of suicide ideation and % for suicide attempts has been found using nlp (fernandes et al. ) . a meta-analysis of studies of prediction of suicide using traditional methodologies found only slightly better than chance predictions and no improvement in accuracy in years (franklin et al. b ). recent ml decision support aids using large-scale biological and other data have been useful in predicting responses to different drugs for depression (dwyer et al. ). triantafyllidis and tsanas ( ) conducted a literature review of pragmatic evaluations of nonpharmacological applications of ml in real-life health interventions from january through november , following prisma guidelines. they found only eight articles that met their criteria from citations screened. three dealt with depression and the remainder with other health conditions. six of the eight produced significantly positive results, but only three were rcts. there has been little rigorous research to support ai in real-world contexts. accuracy of prediction is one of the putative advantages of ai. but the advantage of predicting outcomes is not as relevant if a client prematurely leaves treatment. thus, predicting premature termination is one of the key goals of an ai approach. in a pilot study to test whether ai could be beneficial in predicting premature termination, bohus et al. ( ) were not able to adequately predict dropouts using different ml approaches with responses to the borderline symptom list (bsl- ). however, they obtained some success when they combined the questionnaire data with personal diary questionnaires from patients, although they note that the sample is too small to draw any strong conclusions. this pilot study illustrates the importance of what data goes into the data set as well as our lack of knowledge of the data requirements we need to have confidence in as we select the appropriate data. duwe and kim ( ) compared statistical methods including ml approaches on their accuracy in predicting recidivism among , offenders. they found the newer ml algorithms generally performing modestly better. kessler et al. ( ) used data from u.s. army and department of defense administrative data systems to predict suicides of soldiers who were hospitalized for a psychiatric disorder (n = , ). within one year of hospitalization, ( . %) of the soldiers committed suicide. they used a statistical prediction rule based on ml that resulted in a high validity auc value of . . kessler and his colleagues have continued this important work, which was discussed earlier. another approach to prediction was taken by pearson et al. ( ) in predicting depression symptoms after an -week internet depression reduction program using participants. they used an elastic net and random forest ml ensemble (combination) and compared it to a simple linear autoregressive model. they found that the ensemble method predicted an additional % of the variance over the non-ml approach. the authors offer several good technical suggestions about how to avoid some common errors in using ml. moreover, the ml approach allowed them to identify specific module dosages that were related to outcomes that would be more difficult to determine using standard statistical approaches (e.g., detecting nonlinear relationships without having to specify them in advance). however, not all attempts to use ai are successful. pelham et al. ( ) compared logistic regression and five different ml approaches to typical sum-score approaches to identify boys in the fifth grade who would be repeatedly arrested. ml performed no better than simple logistic regression when appropriate cross-validation procedures were applied. the authors emphasize the importance of cross-validation in testing ml approaches. in contrast, a predictive study of people with first-episode psychosis used ai to successfully predict poor remission and recovery one year later based only on baseline data (leighton et al. ) . the model was cross validated on two independent samples. a comprehensive synthesis of the literature of studies that used ml or big data to address a mental health problem illustrated the wide variety of uses that currently exist; however, most dealt with detection and diagnosis (shatte et al. ) . a critical view of the way psychiatry is practiced for the treatment of depression and how ai can improve that practice is provided by tan et al. ( ) . they note that most depression is treated with an "educated-guess-and-check approach in which clinicians prescribe one of the numerous approved therapies for depression in a stepwise manner" (p. ). they posit that ai and especially deep learning have the ability to model the heterogeneity of outcomes and complexity of psychiatric disorders through the use large data sets. at this point, the authors have not provided any completed studies that have used ai, but two of the authors are shareholders in a medical technology company that is developing applications using deep learning in psychiatry. we are beginning to see commercial startups take an interest in mental health services even though the general health market is considerably bigger. entrepreneurially motivated research may be important for the future of ai growth in mental health services, with traditional federal research grants to support this important developmental work, including such mechanisms as the small business innovation research (sbir) program and the r and r nih funding mechanisms. one of the few studies that go beyond just prediction and actually attempt to develop a personalized treatment was conducted by fisher et al. ( ) . in a proof of concept study, the authors used fisher's modular model of cognitive-behavioral therapy (cbt) and algorithms to develop and implement person-by-person treatments for anxiety and mood disorders for adults. the participants were asked to complete surveys four times a day for about days. the average improvement was better than found in comparison benchmark studies. the authors state that this is the first study to use pre-therapy multivariate time series data to generate prospective treatment plans. rosenfeld et al. ( ) describe several treatment delivery approaches that utilize ai. woebot, for example, is a commercial product to provide cbt-based treatment using ai. the clients interact with woebot through instant messaging that is later reviewed by a psychologist. it has been shown to have short-term effectiveness in reducing phq- scores of college students who reported depression and anxiety symptoms. the authors are optimistic that approaches like the ones described will lead to more widely available and efficacious treatment modalities. applications of ml to addiction studies was the focus of a systematic review by mak et al. ( ) . they did an extensive search of the literature until december and could find only articles. none of the studies involved evaluating a treatment. i want to distinguish between the use of computer-assisted therapy, especially that provided through mobile apps, and the use of ai. in a review of these digital approaches to providing cbt for depression and anxiety, wright et al. ( ) point out while many of these apps have been shown to be better than no treatment, they usually do not use ai to personalize them. thus, they are less relevant to this paper and are not discussed in depth. ecological momentary interventions (emis) are treatments provided to patients between sessions during their everyday lives (i.e., in real time) and in natural settings ). these interventions extend some aspects of psychotherapy to patients' daily lives to encourage activities and skill building in diverse conditions. in the only systematic review available of emis, colombo et al. ( ) found only eight studies that used emis to treat major depression, with only four different interventions. the common factor of these four interventions is that they provide treatment in real-time and are not dependent on planned sessions with a clinician. the authors report that participants were generally satisfied with the interventions, but there was variability in compliance and dropout rates among the programs. with only two studies that tested for effectiveness with rcts, there is clearly a need for more rigorous evaluations. momentary reminders are typically used for behaviors such as medication adherence and management of symptoms. the more complex emis use algorithms to optimize and personalize systems. they also can use algorithms that changes the likelihood of the presentation of a particular intervention over time, based on past proximal outcomes. schueller et al. ( ) note that emis are becoming more popular as a result of technological advances. these authors suggest the use of micro-randomized trials (mrts) to evaluate them. an mrt uses a sequential factorial design that randomly assigns an intervention component to each person at multiple randomly chosen times. each person is thus randomized many times. this complex design represents the dynamic nature of these interventions and how their outcomes correspond to different contextual features. ai is often used to develop algorithms to optimize and personalize the mrt over time. one interesting algorithm, called a "bandit algorithm," changes the intervention presented based on a past proximal outcome. as an example, schueller et al. describe a hypothetical study to reduce anxiety through two different techniques-deep breathing and progressive muscle relaxation. the bandit algorithm may start the presentation of each technique with equal frequency but then shift more to the one that appears to be most successful for that individual. thus, each treatment (a combination of deep breathing and progressive muscle relaxation) would be different for each person. unlike rcts, this method does not use group-level outcomes of average effect sizes but uses individual-level data. in the future, we might have personal digital mental health "therapists" or assistants that can deliver individualized combinations of treatments based on algorithms developed with ai that are data driven. of course, this approach is best suited for these momentary interventions and would be difficult if not impossible to successfully apply to traditional treatment. i consider explicating the relationship between ai and causality to be a key factor in understanding whether ai is to be seen as replacing or as supplementing rcts. toward that end, i first consider whether observational data can replace rcts using ai. second, should a replacement not seem currently feasible, i explore ways to design studies that combine ai and rcts to evaluate whether the ai approach produces better outcomes than non-ai enhanced interventions. the journal prevention science devoted a special section of an issue to new approaches for making causal inferences from observational data (wiedermann et al. ). an example is the paper by shimizu ( ) that demonstrates the use of non-gaussian analysis tools to infer causation from observational data under certain assumptions. malinsky and danks ( ) provide an extended discussion of the use of causal discovery algorithms to learn causal structure from observational data. in a similar fashion, blöbaum et al. ( ) present a case for inferring causal direction between two variables by comparing the least-squares errors of prediction in both possible directions. using data that meet some assumptions, they provide an algorithm that requires only a regression in both causal directions and a comparison of the least-square errors. lechner's ( ) paper focuses on identifying the heterogeneity of treatment effects at the finest possible level or identifying what he calls groups of winners and losers who receive some treatment. hassani et al. ( ) hope to build a connection between researchers who use big data analysis and data mining techniques and those who are interested in causality analysis. they provide a guide that describes data mining applications in causality analysis. these include entity extractions, cluster analysis, association rule, and classification techniques. the authors also provide references to studies that use these techniques, key software, substantive areas in which they have been used, and the purpose of the applications. this is another bit of evidence that the issue of causality is being taken seriously and that some progress is being made. however, because of the newness of these publications, there is a lag in publications that are critical of these approaches; for example, d'amour ( ) provides a technical discussion about why some approaches will not work but also suggests that others may be potentially effective. clearly, caution is still warranted in drawing causal conclusion from observational data. chen ( ) provides a very interesting discussion of ai and causality but not from the perspective of the rct issue that i raise here but as a much broader but still relevant point of view. he advances the key question about whether ai technology should be adopted in the medical field. chen argues that there are two major deficits in ai, namely the causality deficit and the care deficit. the causality deficit refers to the inferior ability of ai to make accurate casual inferences, such as diagnosis, compared to humans. the care deficit is the comparative lack of ability of ai to care for a patient. both deficits are interesting, but the one most germane to this paper is the causality deficit. chen notes that ai represents statistical and not causal reasoning machines. he argues that ai is deficient compared to humans in causal reasoning, and, moreover, he doubts that there is a feasible way to deal with this lack of comparability in reasoning. he believes that ai is a model-blind approach in contrast to a human's more model-based approach to causal reasoning. thus, causation for chen is not an issue of experimental methodology (he never mentions rcts in his paper), but a characteristic associated with humans and not computers. chen does recognize that ai researchers are attempting to deal with the causality issue, for example, by briefly describing pearl's ( ) directed acyclic graphs and nonparametric structural equation models. but chen is skeptical that either the causality or care deficits will be overcome. he concludes that ai is best thought of as assisting humans in medical care and not replacing them. the relationship between ai and humans is a major concern of this paper. caliebe et al. ( ) see big data, and i would assume ai, as contributing to hypotheses generation that could then be tested in rcts. the critical issues they see are related to the quality and quantity of big data. they quote an institute of medicine (iom) report that refers to the use of big data and ai in medicine as "learning healthcare systems" and states that these systems will "transform the way evidence on clinical effectiveness is generated and used to improve health and health care" (institute of medicine , p. ). moreover, in , the iom suggested that alternative research methodologies will be needed. they do not acknowledge the conundrum that i have raised here; moreover, they do not see any need to consider changing any of our methodology or analyses. i have found many individual papers that describe how to solve the causality problem with ai (e.g., kuang et al. ; pearl ) . although these papers are complex, their mere existence gives me hope that this problem is being seriously considered. in addition to the statistical and validity issues in trying to replace rcts with observational data, there is the feasibility question. although the data studied in much of the research reported in this paper are in the medical domain and deal primarily with medications, the characteristics of these data have some important lessons for mental health services. bartlett et al. ( ) identified trials published in the top seven highest impact medical journals. they then determined whether the intervention, medical condition, inclusion and exclusion criteria, and primary end points could be routinely obtained from insurance claims and/or electronic health data (ehr) data. these data are recognized by the fda as what they term real-world evidence. they found that only % of the u.s.-based clinical trials published in highimpact journals in could be feasibly replicated through analysis of administrative claims or ehr data. the results suggest that potential for real-world evidence to replace clinical trials is very limited. at best, we can hope that they can complement trials. given the paucity of data collected in mental health settings, the odds are that such data are even less available. suggestions for improving the utility of real-world data for use in research are provided in an earlier article by some of these authors (dhruva et al. ). pearl ( ) posits causal information in terms of the types of questions that, in his three-level model, each level answers. his first level is association; the second, intervention; and the third, counterfactual. association is simply the statistical relationship or correlation. there is no causal information at this first level. the higher order levels can answer questions about the lower levels but not the other way around. counterfactuals are the control groups in rcts. they represent what would have happened if there had been no intervention. to pearl, this unidirectional hierarchy explains why ml, based on associations, cannot provide causal statements like rcts, which are based on counterfactuals. however, as noted earlier, pearl does present an approach using what he calls structural causal models to "extract" causal relationships from associations. pearl describes seven "talks" and accompanying tools that are accomplished in the framework provided by the structural causal models that are necessary to move from the lower levels to the counterfactual level to allow causal inferences. i would anticipate that there will be direct comparisons between this approach to causality and the randomized experiments like those done in program evaluation (bickman and reich ; boruch et al. ) . theory development or testing is usually not thought of as a strength of ai; instead, its lack of transparency, that is, the lack of explanatory power that would enable us to identify models/mechanisms that underlie outcomes, is seen as a major weakness. coutanche and hallion ( ) present a case for using feature ablation to test theories. this technique involves the removal or ablation of features from algorithms that have been thought to be theoretically meaningful and then seeing if there is a significant reduction in the predictive accuracy of the model. they have also studied whether the use of a different data set affects the predictive accuracy of a previously tested model in theoretically useful ways. they present a very useful hypothetical application of their approach to test theories using ai. it is clear that ai can be very useful in making predictions, but can it replace rcts? can ai perform the major function of rcts, that of determining causality? the dependence on rcts was one of the major limitations i saw as hindering the progress of mental health services research. while rcts have their flaws, they are still considered by most as the best method for determining causal relationships. is ai limited to being a precursor in identifying those variables that are good candidates for rcts because they have high predictive values? the core conceptual problem is that while it is possible to compare two different but theoretically equivalent groups, one receiving the experimental treatment and the other the control condition, it is not possible to compare the same individuals on both receiving and not receiving the experimental treatment. rcts produce average effect sizes, but the ultimate purpose of precision mental health is to predict individualized effects. how do we reconcile these two very different aims? one approach is to use ai to identify the most predictive variables and then test them in a randomized experiment. let us take a group of patients with the same disorder or problem. there may be several alternative treatments, but the most basic concept is to compare two conditions. in one condition, call it the traditional treatment condition in the rct, everyone in that condition gets the same treatment. it is not individualized. in the second condition, call it the ai condition, everyone gets a treatment that is based on prior ai research. the latter may differ among individuals in dosage, timing, type of treatment, and so on. the simplest is medication that differs in dosage. however, a more nuanced design is a yoked design used primarily in operant and classical conditioning research. there have been limitations associated with this design, but these problems apply to conditioning research and not the application considered here (church ) . to separate the effects of the individualization from the differences in treatment, i suggest using a yoked design. in this design, individuals who would be eligible to be treated with either the standard treatment or the ai-selected treatment would be yoked, that is, paired. which participant of the pair received which condition would be randomized. first, the eligible participants would be randomly divided into two groups. the individuals in the ai group would get a treatment that was precisely designed for each person in that group, while those in the yoked control group would not; instead, those in the control group would receive the treatment that had been designed for his or her partner in the ai group. in this way, each participant would receive the same treatment, but only the ai group participants would be receiving individualized treatment. if the ai approach is superior, we would expect those in the ai group to have a superior average treatment effect compared to the control group, who received a treatment matched not to their individual characteristics but to those in the ai group. we could also use an additional control group where the treatment is selected by a clinician. while this design would not easily identify which characteristics were responsible for its success, it would demonstrate whether individualized ai-based treatment was the causal factor. that is, we could learn that on the average, a precision approach is more effective than a traditional approach, but we would not be able to identify from this rct which particular combination of characteristics made it more effective. of note is that the statistical power of this design would depend on the differences among the participants at baseline. for example, if the individuals were identical on measured covariates, then they would get the same personalized treatment, which practically would produce no useful information. instead of yoking participants based on randomly assigning them as in the above example, we could yoke them on dissimilarity and then randomly assign each individual in the pair to ai-based treatment or a control condition that could be the same ai treatment or a clinician-assigned treatment. however, interesting this would be from a methodical point of view, i think this would also bring up ethical issues that are discussed next. of course, as with any rct, there are ethical issues to consider. in many rcts, the control group may receive standard treatment, which should not present any unusual ethical issues. however, in a yoked design, the control group participants will receive a treatment that was not selected for them on the basis of their characteristics. moreover, the yoked design would make the formulation of the informed consent document problematic because it would have to indicate that participants in the control group would receive a treatment designed for someone else. one principle that should be kept in mind is equipoise: there should be consensus among clinicians and researchers that the treatments, a priori, are equivalent. in a yoked design, we must be assured that none of individualized treatments would harm the yoked control group members, and moreover, that there is no uniform agreement that the individualized treatment would be better for the recipient. that is, the research is designed to answer a question about relative effectiveness for which we do not know the answer. almost all of the research previously cited in this paper has dealt with psychosocial interventions, along with some research on interventions with medications. clearly these are the two main approaches taken in providing services for mental health problems. however, in the last decade, a new approach to understanding mental illness has emerged from the field of psychoneuroimmunology. this relatively new field integrates research on psychology, neuroscience, and immunology to understand how these processes influence each other and, in turn, human health and behavior (slavich ). i want to explore this relatively new approach to understanding mental health because i believe that it is a potentially rich field in which to apply ai. slavich and irwin ( ) have combined diverse areas to show how stressors affect neural, physiologic, molecular, and genomic and epigenetic processes that mediate depression. they labeled this integrative theory the social signal transduction theory of depression. in a recent extension of this work, slavich ( ) proposed social safety theory, which describes how social-environmental stressors that degrade experiences of social safety-such as social isolation and rejection-affect neural, immunologic, and genomic processes that increase inflammation and damage health. a key aspect of this perspective is the role of inflammatory cytokines as key mediators of the inflammatory response (slavich ) . cytokines are the biological endpoint of immune system activity and are typically measured in biobehavioral studies of stress and health. cytokines promote the production of c-reactive protein, which is an inflammatory mediator like cytokines, but which also is a biomarker of inflammation that is assessed with a blood test. cytokines also interact with the central nervous system and produce what have been labeled "sickness behaviors," which include increased pain and threat sensitivity, anhedonia, fatigue, and social-behavioral withdrawal. while the relationship between inflammation and depression is well-established in adults, a systematic review and meta-analysis of studies with children and adolescents concluded that because of the small number of studies, more evidence was needed before drawing a similar conclusion for youth (d'acunto et al. ) . in contrast, a major longitudinal study of more than adults followed over years found that participants who had stable high c-reactive protein levels were more likely to report clinically significant late-life depression symptoms (sonsin-diaz et al. ) . chronic inflammation has been shown to be present in many psychiatric disorders including depression, schizophrenia, and ptsd, as well as in many other somatic and physical disease conditions (furman et al. ) . chronic inflammatory diseases have been shown to be a major cause of death. a typical inflammatory response occurs when a threat is present and then goes away when there is no longer a threat. however, when the threat is chronic and unresolved, systemic chronic inflammation can occur and is distinct from acute inflammation. chronic inflammation can cause significant damage to tissues and organs and break down the immune system tolerance. what is especially interesting from a behavioral health perspective is that inflammatory activity can apparently be initiated by any psychological stressor, real or imagined. thus, social and psychological stressors such as negative interpersonal relationships with friends and family, as well as physical stressors, can produce inflammation, which leads to increased risk of mental and physical health problems. this inflammatory response initially can have positive effects in that it can help increase survival in the short term, but it can also lead to a dysfunctional hypervigilance and anxiety that increases the risk of serious mental illness if chronic. the "cytokine storm" experienced by many covid- patients is an example of the damage an uncontrolled immune response can cause (konig et al. ). although we do not know a great deal about how this process operates, it is clear that there is a strong linkage between inflammatory responses and mental disorders such as depression. the role of the immune system in disease, especially brain inflammation related to brain microglial cells (i.e., neuroinflammation), is also receiving attention in the popular press (nakazawa ). psychoneuroimmunology research has explicated the linkage between the brain and the immune system, showing how stress affects the immune system, and how these interactions relate to mental illness. the relationships between these constructs suggest interventions that can be used to improve mental health. but much research remains to be done to identify specific processes and effective interventions. research will require multidisciplinary teams to produce personalized interventions guided by each patient's specific level of neuroinflammation and genetic profiles. this process will need to be monitored by continuous feedback that i believe will be made more feasible with the application of ai. at present, there are some existing interventions that appear to be aligned with this approach that are being explored. these include the following. three anti-inflammatory medications have been found to reduce depressive symptoms in well-designed rcts. these agents include celecoxib, usually used for treating excessive inflammation and pain, and etanercept and infliximab, which are used to treat rheumatoid arthritis, psoriasis, and other inflammatory conditions (slavich ) . however, there has not been a great deal of research in this area, so caution is warranted. a recent well-designed rct with depressed youth tested aspirin, rosuvastatin (a statin), and a placebo and found no significant differences in depression symptoms (berk et al. ). a meta-analysis explored the possible link between different types of psychosocial interventions, such as behavior therapy and cbt, and immune system function (shields et al. ) . the authors examined eight common psychosocial interventions, seven immune outcomes, and nine moderating factors in evaluating rcts. they found that psychosocial interventions were associated with a . % improvement in good immune system function and a . % decrease in detrimental immune function, on average. moreover, the effects lasted for at least months and were consistent across age, sex, and intervention duration. the authors concluded that psychosocial interventions are a feasible approach for influencing the immune system. repetitive transcranial magnetic stimulation (rtms) has been found to be an effective treatment for several mental illnesses, especially treatment-resistant depression (mutz et al. ; somani and kar ; voigt et al. ) . while the literature is not clear on how rtms produces its effect (noda et al. ; peng et al. ) , i was curious about its relationship to neuroinflammation. i could find little in the research literature that addressed the relationship between inflammation and rtms; therefore, i conducted an informal survey of rtms researchers who have published rtms research in peer-reviewed journals and asked them the following: i suspect that rtms is related to inflammation but the only published research that i could find on that relationship was two studies dealing with rats. are you aware of any other research on this relationship? in addition, do you know of anyone using ai to investigate rtms? i received replies from all but of the researchers. about half said they were aware of some research that linked rtms to inflammation and supplied citations. in contrast, only % were aware of any research on rtms and ai. the latter noted some research that used ai on eegs to predict rtms outcomes. a most informative response was from the author of a review article that dealt with several different nontraditional treatments including rtms on the hypothalamic-pituitary-adrenal (hpa) axis and immune function in the form of cytokine production in depression (perrin and parianti ) . the authors found relevant human studies ( studies using rtms) but were unable to conduct the metaanalysis because of significant methodological variability among studies. but they concluded that non-convulsive neurostimulation has the potential to impact abnormal endocrine and immune signaling in depression. moreover, given that there is more information available than on other neurostimulation techniques, the research suggests that rtms appears to reduce cytokines. finally, there is some support from animal models (rats) that rtms can have an anti-inflammatory effect on the brain and reduce depression and anxiety (tiana et al. ). moreover, four published studies showed that the efficacy of rtms for schizophrenics could be predicted koutsouleris et al. ( b) . three other studies were able to use ml and eeg to predict outcomes of rtms treatment for depression (bailey et al. ; hasanzadeh et al. ) . the existing literature indicates that metabolic activity and regional cerebral blood flow at the baseline can predict the response to rtms in depression (kar ) . as these baseline parameters are linked to inflammation, it is worth studying responses to rtms that predict inflammation. as noted by one of the respondents, "in summary, it is a relatively new field and there are no major multi-site machine learning studies in rtms response prediction" (n. koutsouleris, personal communication, march , ) . one of the significant limitations of measurement in mental health is the absence of robust biomarkers of inflammation. furman et al. ( ) caution us that "despite evidence linking sci [systemic chronic inflammation] with disease risk and mortality, there are presently no standard biomarkers for indicating the presence of health-damaging chronic inflammation" (p. ). however, some biomarkers that are currently being explored for inflammation may be of some help. for example, furman et al. ( ) are hopeful that a new approach using large numbers of inflammatory markers to identify predictors will produce useful information. a narrative review of inflammatory biomarkers for mood disorders was also cautious in drawing any conclusions from extant research because of "substantial complexities" (chang and chen ) . it is also worth noting the emerging area of research on gut-brain communication and the relationship between microbiome bacteria and quality of life and mental health (valles-colomer et al. ) . however, there is need for more research on the use of biomarkers. the area of inflammation and mental health offers an additional pathway to uncovering the causes of mental illness but also, most importantly for this paper, potential services interventions beyond traditional medications and psychosocial interventions. given the complexity, large number of variables from diverse data sets, and the emerging nature of this area, it appears that ai could be of great benefit in tying some potential biomarkers to effective interventions designed to produce better clinical outcomes. however, some caution is needed concerning the seemingly "hard data" provided by biomarkers. for example, elliot et al. ( ) found in a meta-analysis of experiments that one widely used biomarker, task-fmir, had poor overall reliability and poor test-retest reliability in two other large studies. they concluded that these measures were not suitable for brain biomarker research or research on individual differences. as noted in several places in this paper, ai is not without its problems and limitations. the next section of the paper discuses several of these problems. ai may force the treatment developer to make explicit choices that are ethically ambiguous. for example, automobile manufacturers designing fully autonomous driving capabilities now have to be explicit about whose lives to value more in avoiding a collision-the driver and his or her passengers or a pedestrian. should the car be programmed to avoid hitting a pedestrian, regardless of the circumstances, even if it results in the death of the driver? mental health services do not typically have such clear-cut conflicts, but the need to weigh the potential side effects of a drug against potential benefits suggests that ethical issues will confront uses of ai in mental health. some research has shown that inherent bias in original data sets has produced biased (racist) decisions (obermeyer et al. ; veale and binns ) . an unresolved question is who has the responsibility for determining the accuracy and quality of original data set (packin and lev-aretz ) . data scientists operating with data provided by others may not have sufficient understanding of the complexity of the data to be sensitive to its limitations. moreover, they may not consider it their responsibility to evaluate the accuracy of the data and attend to its limitations. librenza-garcia ( ) provides a comprehensive review of ethical issues in the use of large data sets with ai. the ethical issues in predicting major mental illness are discussed by lawrie et al. ( ) . they note that predictive algorithms are not sufficiently accurate at present, but they are progressing. the authors raise questions about whether people want to know their risk level for major psychiatric disorders, about individual and societal attitudes to such knowledge and the possible adverse effects of sharing such data, and about the possible impact of such information on early diagnosis and treatment. they urge conducting research in this area. related to the ethics issue but with more direct consequences to the health provider is the issue of legal responsibility in using an ai application. it is not clear what the legal liability is for interventions based on ai that go wrong. who is responsible for such outcomes-the person applying the ai, the developer of the algorithm, or both? price ( ) points out that providers typically do not have to be concerned about the legal liability of a negative outcome if they used standard care. thus, if there are negative outcomes of some treatment but that treatment was the standard of care, there is usually no legal liability. however, currently ai is probably not seen as the standard of care in most situations. while this will hopefully change as evidence of the effectiveness of ai applications develops, currently the healthcare provider is at greater risk of legal liability in using an ai application that is different from the standard of care. i have previously discussed the insufficient evidence for the effectiveness of many of the interventions used in mental health services. this lack of strong evidence has implications for the use of ai in mental health services. in an insightful article on using ai for individual-level treatment predictions, paulus and thompson ( ) make several key observations and suggestions that are very relevant to the current paper. the authors summarize several meta-analyses of the weak evidence of effectiveness of mental health interventions and come to conclusions similar to those i have already stated. they also identify similar factors i have focused on in accounting for the modest effect sizes found in mental health rcts. they point out that diagnostic categories are not useful if they are not aggregating homogenous populations. they suggest that what i call the diagnostic muddle may result from the nature of mental disorders themselves, for which there are many causes at many different levels, from the genetic to the environmental. thus, there is no simple explanatory model. paulus and thompson note that prediction studies rarely account for more than a very small percentage of the variance. they recommend conducting large, multisite pragmatic rcts that are clearly pre-defined with specific ml models and variables. predictive models generated by this research then need to be validated with independent samples. this is a demanding agenda, but i think it is necessary if we are going to advance mental health services with the help of ai. treatments are often considered black boxes that provide no understanding of how and why the treatment works (kelley et al. ; bickman b) . the problem of lack of transparency is compounded in the use of deep neural networks (samek et al. ) . at present we are not able to understand relationships between inputs and outcomes, because this ai technique does not adequately describe process. deep neural networks may contain many hidden layers and millions of parameters (de choudhury and kikkoman ). however, this problem is now being widely discussed, and new technologies are being developed to make ai more transparent (rauber et al. ; kuang et al. ). i do not believe it is possible to develop good theories of treatment effectiveness without this transparency. this is an important limitation of efforts to improve mental health services. but how important is this limitation? early in my program evaluation career, i wrote about the importance of program theory (bickman (bickman , . i argued that if individual studies were going to be conceptually useful, beyond local decisions such as program termination, then they must contribute to the broader goal of explaining why certain programs were effective and others not. this is in contrast to the worth and merit of a local program. a theory based evaluation of the program must add to our understanding of the theory underlying the program. while i still believe that generalizing to a broad theory of why certain interventions work is critical, at present it may be sufficient simply to increase the accuracy of our predictions, regardless of whether we understand why. as stephens-davidowitz ( ) argues, "in the prediction business, you just need to know that something works, not why" (p. ). however, turing award winner judea pearl argued in his paper theoretical impediments to machine learning with seven sparks from the causal revolution ( ) that human-level ai cannot emerge from model-blind learning machines that ignore causal relationships. one of the positive outcomes of the concern over transparency is the development of a subfield of ai that has been called explainable artificial intelligence (xai). adai and berrada ( ) present a very readable description of this movement and show that it has been a growing area since . they are optimistic that research in this area will go a long way toward solving the black box problem. large data sets are required for some ai techniques, especially deep neural networks. while such data sets may be common in consumer behavior, social media, and hospitalbased electronic health records, they are not common in community-based mental health services. the development and ownership of these data sets may be more important (and profitable) than ownership of specific ai applications. there is currently much turmoil over data ownership (mittelstadt ) . ownership issues are especially important in the mental health field given the sensitivity of the data. in addition to the size and quality of the data set, longitudinal data are necessary for prediction. collecting longitudinal data poses a particular problem for community-based services given the large treatment drop-out rate. in addition to the characteristics of the data, there is the need for competent data managers of large complex data sets. the data requirements for mental health applications are more demanding than those for health in general. first, mental health studies usually do not involve the large samples that are found in general health. for example, the wellknown physicians' health study of aspirin to prevent myocardial infarction (mi) utilized more than , doctors in a rct (steering committee of the physicians' health study research group ). they found a reduction in mi that was highly statistically significant: p < . . the trial was stopped because it was thought that this was conclusive evidence that aspirin should be adopted for general prevention. however, the effect size was extremely small: a risk difference of . % with r = . (sullivan and feinn ) . a study this size is not likely to occur in mental health. moreover, such small effects would not be considered important even if they could be detected. it is unlikely that very large clinical trials such as the aspirin study would ever be conducted in mental health. thus, it is probable that data will have to be obtained from service data. but mental health services usually do not collect sufficiently fine-grained data from clients. while i was an early and strong proponent of what i called a measurement feedback system for services (bickman a) , recent research shows that the collection of such data is rare in the real world. until services start collecting these data as part of their routine services, it is unlikely that ai will have much growth with the limited availability of relevant data. there is, of course, a chicken and egg problem. a major reason why services do not collect data is the limited usefulness of data in improving clinical care. while ai may offer the best possibility of increasing the usefulness of regularly collected data, such data will not be available until policy makers, funders, and providers deem it useful and are willing to devote financial resources to such data collection analysis. at present, there are no financial incentives for mental health providers to collect such data even if they improved services. moustafa et al. ( ) made the interesting observation that psychology is behind other fields in using big data. ai and big data are not considered core topics in psychology. the authors suggest several reasons for this, including that psychology is mostly theory-and hypothesis-driven rather than data-driven, and that studies use small sample sizes and a small number of variables that are typically categorical and thus are not as amenable to ai. moreover, most statistical packages used by psychologists are not well-equipped to analyze large data sets. however, the authors note that the method of clustering and thus differentiating among participants is used by psychologists and is in many ways similar to ai, especially deep neural networks, in trying to identify similar participants. using ml methods such as random forest algorithms, the investigator can identify variables that best explain differences among groups or clusters. instead of the typically few variables used by psychologists, ai can examine hundreds of variables. as a note of caution, rutledge et al. ( ) warn that "there is no silver bullet that can replace collecting enough data to generate stable and generalizable predictions" (p. ). while there are techniques that are often used in low sample size situations (e.g., the elastic net and tree-based ensembles), researchers need replications with independent samples if they are to have sufficient confidence in their findings. moreover, since big data are indeed big, they are easily misunderstood as automatically providing better results through smaller sampling errors. it is often not appreciated that the gain in precision drawn from larger samples may well be nullified by the introduction of additional population variance and biases. finding competent big data managers, data scientists, and programmers is a human resource problem. in my experience, ai scientists who are able and want to collaborate with mental health services researchers are rare. industry pays a lot more for these individuals than universities can afford. moreover, even within the health field, mental health is a very small component of the cost of services, so it is often ignored in this area. difficulty and resistance are encountered in the implementation of new technologies. clinicians are reluctant to adopt new approaches and to engage clients in new approaches and data collection procedures. community mental health services have been slow to successfully adopt new technologies (crutzen et al. ; lattie et al. ; yeager and benight ) . in their mixed methods study of community clinicians, crutzen et al. ( ) found there were concerns about privacy, the wide range of therapeutic techniques used, disruptions in trust and alliance, managing crises, and organizational issues such as billing and regulations contained in the privacy rule established by the health insurance portability and accountability act of (hipaa) that inhibited the use of new technologies. moreover, our current reimbursement policies do not support greater payment for better outcomes. thus, there is little or no financial incentive for hard-pressed community services to improve their services at their own expense. in fact, i would argue that there is a disincentive to improve outcomes since it results in increased costs (at least initially), organizational disruption and potentially a loss of clients if it takes less time and effort to successfully treat them. an interesting meta-issue has emerged from the widespread and ever-increasing investment in ai in healthcare. in a perceptive "viewpoint" published in jama, emanuel i would be happy to serve as a "matchmaker" for any ai programmers, data scientists (etc.), or behavioral scientists who are interested in collaborating on mental health projects. just contact me describing your background and interests and i will try to put together likeminded researchers. and wachter ( ), argue that the major challenge facing healthcare is not that of obtaining data and new analytics but the achievement of behavior change among both clinicians and patients. they point out the major failures of google and microsoft in not recognizing the problems in translating evidence into practice in connection with their large, web-based repositories for storage of health records, google health and microsoft healthvault, both of which have been discontinued. they indicate that the long delays in translation are due not primarily to data issues or lack of accurate predictions, but to the absence of behavioral changes needed for adoption of these practices. for example, the collection of longitudinal data has been problematic. another problem they note is that about half the people in the united states are nonadherent with medications. there is a huge gap between knowing what a problem is and actually solving it that "data gurus" seem to ignore. while this translation problem is evident in the sometimes narrow focus of ai promoters, it also represents an opportunity for the behavioral scientists engaged in ai research to marshal their skills and the knowledge gained from years of dealing with similar behavioral issues. the emergence of translational and implementation sciences, the latter more often led by behavioral scientists, can be of great service to the problems of applying ai to healthcare. the field of translational sciences has been developed and well-funded by the nih in recognition of the difficulty in using (i.e., translating) laboratory studies into practice. in , the budget for the clinical and translational science awards (ctsa) program was over a half billion dollars from to . however, as director of evaluation for vanderbilt's medical center's ctsa program for many years, i became very familiar with the difficulties in applying medical research in the real world. mental health is determined by multiple factors. it is unlikely that we will find a single vector such as a virus or a bacterium that causes mental illness. thus, data demands can include multiple systems with biological, psychological, sociological, economic, and environmental factors. within many of these domains, we do not have objective measures such as the lab tests found in medicine. subjective selfreports are prone to many biases, and many of the symptoms are not observable by observers. the lack of a strong theory of mental disorders also makes it difficult to intelligently focus on only a few variables. even with such apparently simple measures that include observations or recordings from multiple informants, we do not have a consensus on how to integrate them (bickman et al. a; martel et al. ). however, i would expect that research generated with ai will contribute not only to improved treatment but also to enhanced theories by including heterogeneous clients and many data sources. confidentiality and trust are key issues in mental health treatment. how will the introduction of ai affect the relationship between client and clinician? as noted earlier, there are problems, especially with deep learning, in interpreting the meaning of algorithmic solutions and predictions. our ability to explain the algorithms to clients is problematic. while many research projects outside of mental health show that combining ai with human judgment produces the best outcomes, this research is still in its infancy. a great deal has been written about ai in the context of medicine, but we need a reality check about the importance of ai in clinical practice. ben-israel et al. ( ) addressed the use of ai in a systematic review of the medical literature from to . the authors focused on human studies that addressed a problem in clinical medicine using one or more forms of ai. of the studies, only % were prospective. none of the studies included a power analysis, and half did not report attrition data. most were proof of concept studies. the authors concluded that their study showed that the use of ai in daily practice of clinical medicine is practically nonexistent. the authors acknowledge that use was defined by publication and that many applications of ai may be occurring without publication. regardless, this study suggests that there are many barriers that must be overcome before ai is more widely used. the self-help industry can provide perspective on digital apps, including some that use ai. it has been estimated that this sector was worth $ . billion in and is expected to be worth $ . billion in (la rosa ). part of that big dollar market is in digital mental health apps, although their precise monetary value is unknown. more to the point is that we know little about the effectiveness of digital apps in the marketplace (chandrashekar ) . moreover, many have warned that these unregulated and untested apps could be dangerous (wykes ) . in the united states, the publication of books is protected by the constitution, so there are no rules governing what can be published in the self-help sector. the market determines what gets accepted and used, regardless of effectiveness or negative side effects. but publication is limited by the cost of publishing and distribution. this is not the case for digital programs, where marginal costs of adding an additional user are negligible. unlike other mental health interventions, there are no licensing or ethical standards governing their use. there are no data being uniformly collected on their use and their effects. although there are u.s. government rules that can be applied to these apps (armontrout et al. ) , the law has many exceptions. the authors note that they could not find a single lawsuit related to software that diagnoses or treats a psychiatric condition. an interactive tool is provided by the federal trade commission to help judge which federal laws might apply in developing an app (https ://www.ftc.gov/tips-advic e/busin ess-cente r/guida nce/mobil e-healt h-apps-inter activ e-tool). it is clear that digital mental health apps will continue to grow. it is critical that services research and funding agencies do not overlook this development that might have potentially positive or negative effects. these are but a few of the many areas or ai needing additional research and potential limitations to be addressed. an excellent discussion of these and other relates issues regarding the potential hype common in the ai field is provided in the national academy of medicine's monograph on the use of ai in healthcare (matheny et al. ) . a thought-provoking paper by hagendorff and wezel ( ) classifies what ai can and cannot do. some of the authors' concerns, such as measurement, completeness and quality of the data, and problems with transparency of algorithms, have already been discussed, so i will describe those that i feel are most relevant to mental health services. the authors describe two methodological challenges, the first being that the data used in ai systems are not representative of reality because of the way they are collected and processed. this can lead to biases and problems with generalizability. second is the concern that supervised learning represents the past. thus, prediction can be based only on the past and not on expectations of change; thus, in some respects, change is inhibited. hagendorff and wezel ( ) also note several societal challenges. one such challenge they cite is that many software engineers who develop these algorithms do not have sufficient knowledge of the sociological, psychological, ethical, and political consequences of their software. they suggest this leads to misinterpretations and misunderstandings about how the software will operate in society. the authors also note the scarcity of competent programmers. i noted earlier that this is especially the case in academia and particularly in the behavioral sciences. the authors highlight that ai systems often produce hidden costs. this includes hardware to run the ai systems and, i would add, the disruptive nature of the intrusion of ai into a workflow. among the technological challenges discussed by hagendorff and wezel, i believe the authors' focus on the big differences between human thinking and intelligent machines is especially relevant to mental health. machines are in no way as complex as human brains; even ai's powerful neural networks, with more than a billion interconnections, represent only a tiny portion of the complexity of brain tissue. in order to obtain better convergence between machines and humans, hagendorff and wezel suggest that programmers follow the three suggestions made by lake et al. ( ) . first, programmers should move away from pattern recognition models, where most development started, to automated recognition of causal relationships. the second suggestion is to teach machines basic physical and psychological theories so that they have the appropriate background knowledge. the third suggestion is to teach machines to learn how to learn so that they can better deal with new situations. the comparison between ai and human thought is the only aspect of their paper where hagendorff and wezel mention causality issues. they note the challenge related to the inflexibility of many algorithms, especially the supervised ones, where simply changing one aspect would result in processing errors because that aspect was not in the training data. machines can be vastly superior to humans in some games where there are very specific inputs for achieving specific goals, but they cannot flexibly adapt to changes like humans. the authors suggest that promising technical solutions are being worked on to deal with this weakness in transferability. all these challenges will affect how well ai will work in mental health services. most problems will probably be solved, but the authors believe that some of these challenges will never be met, such as dealing with the differences between human and computer cognition, which means that ai will never fully grasp the context of mental health services. the machine's construction of a person may lead to a fragmented or distorted self-concept that conflicts with the person's own sense of identity, which seems critical to any analysis of the person's mental health or lack thereof. i do not have a sense of how serious this and the other challenges will be for us in the future, but it is clear that there is a lot more we need to learn. yet another set of concerns, specifically about the variation in ai called deep learning (dl), was enumerated by marcus ( ) , an expert in dl. in a controversial paper in which he identified limitations of dl, he noted that dl "may well be approaching a wall" (p. ) where progress will slow or cease. for example, he noted that dl is primarily a statistical approach for classifying data, using neural networks with multiple layers. dl "maps" the relationships between inputs and outputs. while children may need only a few trials to correctly identify a picture of a dog, dl may need thousands or even millions of labeled examples before making correct identifications without the labels. very large data sets are needed for dl. this is not the case for all ml techniques. i will not attempt to summarize the nine other limitations he sees with dl since many of them are noted elsewhere in this paper. he concludes that dl itself is not the problem; rather, the problem is that we do not fully understand the limitations of dl and what it does well. marcus warns against excessive hype and unrealistic expectations. i am taking this advice personally, and i am not expecting my tesla to be fully autonomous in as predicted by elon musk (woodyard ) . wolff ( ) provided an overview of how some of the problems of deep learning can be ameliorated. he responds to marcus using many of the subheadings in marcus's paper. he calls his framework the sp theory of intelligence, and its application is called the sp computer model (sp stands for simplicity and power). the theory was developed by wolff to integrate observations and concepts across several fields including ai, computing, mathematics, and human perception and cognition, using information compression to unify them. despite these and other concerns previously described, i do think that the advantages of ai for moving mental health services forward outweigh its disadvantages. however, this summary of advantages does not attempt to balance in length or number the disadvantages described above. i do not think it is necessary to repeat the already described numerous applications and potential applications of ai that can be used to improve health services. rather than repeating the numerous applications and potential applications of ai that can be used to improve health services, i highlight only a few key advantages. one of the main advantages is the way ai deals with data. it can handle large amounts of data from diverse sources. this includes structured (quantitative) and unstructured (text, pictures, sound) data in the same analyses. thus, it can integrate heterogeneous data from dissimilar sources. as noted earlier, the inclusion of non-traditional data such as those obtained from remote sensing (e.g., movement, facial expression, body temperature) will be responsible for a paradigm shift in what we consider relevant data. ai, if widely adopted, has the potential to have a major impact on employment. while most of the popular press coverage has been on the potential negative effects of eliminating many jobs, there also are potential positive effects. ai can reduce the costs of many tasks, thus increasing productivity. on the human side, it can streamline routine work and eliminate many boring aspects of work. it thus can free up workers to engage in the more complex and interesting aspects of many jobs. previous innovations have caused job dislocations. the classic loss of jobs in making buggy whips after the advent of automobiles is just one example. the inventions of the industrial age, such as steam engines, displaced many workers but also created many more new jobs. we know that many unskilled or semi-skilled jobs will be affected by ai in a major way. the elimination of cashiers with automated checkouts is now being implemented by amazon. in these stores, you scan your phone, and then ai and cameras take over. you just put products in your bag or cart and leave when you are finished. self-driving cars and trucks will greatly disrupt the transportation industry. we have weathered these disruptions in the past, but even the experts are unsure about how ai will influence jobs. probably the area in which there is the most positive potential in healthcare is when humans and machines collaborate in partnership. here, ai augments human tasks but keeps humans in the center. thus, physicians will no longer be separated by a laptop when speaking to a patient because ai will be able to record, take notes, and interpret the medical visit. we have documented the shortage of mental health workers and the immense gap between mental health needs and our ability to fill them. yes, we can train more clinicians, but our society seems unwilling to offer sufficient salaries to attract and keep such individuals. we have been experimenting with computers as therapists for more than years, but now we finally have the technological resources to develop and implement such approaches. we have started to use chatbots to extend services, but in the near future, ai may allow us to replace the human therapist under some conditions (hopp et al. ). in , the computer scientist and science fiction author vernor vinge developed the concept of a singularity in which artificial intelligence would lead to a world in which robots attain self-consciousness and are capable of what are now human cognitive activities (vinge ) . advocates and critics disagree on whether a singularity will be achieved and whether it would be a desirable development (braga and logan ) . braga and logan, editors of a special issue of information on the singularity and ai, conclude that although ai research is still in the early stage, the combination of human intelligence and ai will produce the best outcomes, but ai will never replace humans and we cannot fully depend on ai for the right answers. while these authors are well-informed, their crystal ball may not be clearer than anyone else's. the relevance of the singularity for healthcare lies in asking whether there will there be a time when ai-based computers are more effective and efficient than clinicians and will replace them. it is a question worth considering. i have presented a comprehensive, wide-ranging paper dealing with ai and mental health services. i have described major deficiencies of our current services, namely the lack of sufficient access, inadequate implementation, and low efficiency/effectiveness. i summarized how precision medicine and ai have contributed to improving healthcare in general and how these approaches are being applied in precision psychiatry and mental health. the paper then describes research that shows how ai has been or can be used to help solve the five problems i noted earlier. i then described the disadvantages and advantages of ai. in reviewing all this information, i believe there is one factor that i have not discussed sufficiently that clearly differentiates the way mental health services have been delivered and the way i expect they will be delivered in the future. i want to focus this last section of the paper on what i believe is the most important and significant change that can occur. this change is reflected in a simple question: is a human clinician necessary to deliver effective and efficient mental health services? i believe the answer to this question does not depend on the occurrence of the singularity but lies in the growth of ai research and its application to mental health services. i think there is widespread agreement that there are significant problems with diagnoses and the quality of our measures. moreover, most will probably agree that if ai can improve diagnoses and measures, then we should use utilize ai and let the results speak for themselves. the dependence on rcts will probably not be resolved by ai research, but ai can clearly help inform what should be tested in rcts. however, our current services overwhelmingly depend on human clinicians to deliver treatment. the problem with learning and feedback is that it requires clinicians to learn how to improve treatment over time with feedback. we are still uncertain about how well clinicians can learn from experience, training, and education (bacon ) . we also lack evidence of the best way to provide feedback to enhance that learning (bickman a; dyason et al. ). the problem of treatment precision is also currently tied to having the clinician deliver the treatment. while we can expect ai to deliver more precise information about treatment planning, we still depend on the clinician to interpret and deliver it with fidelity with some evidence-based model. a precision approach requires the clinician to systematically deliver treatment that is most appropriate to a specific client. we do not have good evidence that most clinicians can do that. i believe no other issue generates a bigger emotional response than the idea of the changing the role of the clinician. no other issue has the economic impact on services as the position of the clinician. i believe this issue is the most critical to the future of mental health services and will be most affected by ai. i note that in in writing an introduction to an extensive special issue of this journal called "therapist effects in mental health service outcome" (king ) , the authors of the introduction to that issue not did not note the potential role of ai in affecting clinicians (king and bickman ) . change is happening rapidly. mental health services are not alone in facing the issue of the role of humans, although human clinicians are probably more central to the provision of mental health services than other health services. a similar issue of the role of humans in the provision of services is being played out in surgery. surgery has been using robots for over years (bhandari et al. ), but the uptake has been slow for a variety of reasons. the next iteration of robot use is a move from using robots guided by surgeons to using robots assisted by ai and guided by surgeons. the use of ai may be seen as an intermediate step to fully autonomous ai-based robots not guided by surgeons. however, it is very clear that this progression is speculative and will take a long time to happen, if ever, given the consequences of errors. closer to our everyday experience is the similar path that the development of autonomous driving involves as we move toward the point at which a human driver is no longer needed. will mental health services follow a similar path? since we do not currently have a sufficient amount of research on using ai in treatment alone to inform us, we must look elsewhere for guidance. two bodies of literature are relevant. one deals with the use of computers and other technologies that do not include the use of ai at present, the second with self-help in which the participation of the clinician is minimal or totally absent. first, let us consider the existing literature that contrasts technology-based treatments with traditional face-to-face psychotherapy. then i will present some reviews of self-help research, followed by a description of the small amount of research using ai in treatment. a review of studies of internet-delivered cbt (icbt) to youth, using waitlist controls, supports the conclusion that cbt could be successfully adapted for internet-based treatment (vigerlan et al. ) . in a meta-analytic review of meta-analyses, containing studies of adult use of internet delivered via icbt, the authors concluded that icbt is as effective as face-to-face therapy (andersson et al. ) . hermes et al. ( ) include websites, software, mobile aps, and sensors as instances of what they call behavioral intervention technologies (bit). in their informative article, dealing primarily with implementation, they note that these technologies (they do not mention ai) can relate to a clinician in three ways: ( ) when intervention is delivered by the clinician and supported by bit, ( ) when bit provides the intervention with support from the clinician, or ( ) when intervention is fully automated with no role for the clinician. this schema clearly applies to the ai interventions and the role of clinicians as well. their conceptual model is helpful in understanding the parameters of implementation. they present a comprehensive plan for research to fill in the major gaps in the literature that addresses the question of comparative effectiveness of bit and traditional treatment. carlbring et al. ( ) conducted a systematic review and meta-analysis of eligible studies of ibct versus face-to-face cbt and reported that they produced equivalent outcomes, supporting the conclusions drawn by previous studies. it is also important to consider the issue of therapeutic alliance (ta) and its relationship to internet-based treatment. ta, to a large extent, is designed to capture the human aspect of the relationship between the clinician and the client. there are thousands of correlational studies that have established that ta is a predictor of treatment outcomes (flückiger et al. ) ; however, there are few studies of interventions that show a causal connection between ta and outcomes (e.g., hartley et al. ) . moreover, the very nature of ta as trait-like or state-like, which is central to causal assumptions, is being questioned and is subject to new research approaches (zilcha-mano ) as well as to questions about how it should be measured regardless of my doubts about the importance of ta, the fluckiger et al. ( ) meta-analysis found similar effect sizes (r = . ) for the alliance-outcome relationship in online interventions and in traditional face-to-face therapies. however, most of these studies were guided by a therapist, so the human factor was not totally absent. penedo et al. ( ) , in their study of a guided internet-based treatment, showed that it was important to align with the client's expectations and goals because these were related to outcomes, but no such relationship existed with the traditional third component of ta, bond with the supporting therapist, implying that ta might play a different role in internetbased treatments. i was trained as a social psychologist and was a graduate student of stanley milgram (of the famous obedience experiments), so i was curious about the research on the relationship between technological virtual agents and humans beyond the context of mental health treatment. several studies cited by schneeberger et al. ( ) showed that robots could get people to do tiring, shameful, or deviant tasks. the authors found that participants obeyed these virtual agents similarly to the way they responded to humans in a video-chat format. the participants did the same number of shameful tasks regardless of who or what was ordering them. moreover, doing the tasks produced the same level of shame and stress in the participant. they concluded that virtual agents and humans appear to have the same influence as human experimenters on participants. of course, there are many limitations associated with generalizing from this laboratory study, which was conducted with female college students in germany, but it does suggest that a great deal of research needs to be done on how humans relate to robots and virtual agents. miner et al. ( ) suggest that use of conversational ai in psychotherapy can be an asset for improving access to care, but there is limited research on efficacy and safety. can we learn about the role of the therapist from therapies that do not involve any therapist or technology? there is substantial research on self-help approaches from written material or what some call bibliotherapy. in general, research has supported the effectiveness of bibliotherapy before the advent of digital approaches. in , cuijpers et al. published a review of the literature that compared face-to face psychotherapy for depression and anxiety with guided selfhelp (i.e., with some therapist involvement) and concluded that they appeared comparable, but because there were so few studies in this comparison, this conclusion should be interpreted with caution. has the situation changed in the last decade? in a comprehensive review and meta-analysis almost years later, bennett et al. ( ) conducted a review and meta-analysis of studies. they concluded that self-help (both guided and unguided) had significant moderate to large effects on reducing symptoms of anxiety, depression, and disruptive behavior. however, there was also very high heterogeneity among the outcomes of these studies. compared to face-to-face therapy, self-help was better than no treatment but slightly worse than face-to-face treatments, guided therapy was better than unguided, and computerized treatment was better than bibliographic treatment. it is important to note that none of the studies were fully powered noninferiority trials, which would be a superior design. the authors concluded that their study showed potential near equivalence for self-help compared to faceto-face interventions, and their conclusions were consistent with several other reviews of self-help for mental health disorders in adults. the paper makes no mention of ai. cuijpers et al. ( ) conducted a network meta-analysis of trials of cbt addressing the question of whether format of delivery (individual, group, telephone-administered, guided self-help, or unguided self-help) influenced acceptability and effectiveness for these adult patients with acute depression. no statistically significant differences in effectiveness were found among these formats except that unguided self-help therapy was not more effective than care as usual but was more effective than a waitlist control group. the authors concluded that treatments using these different formats should be considered alternatives to therapist-delivered individual cbt. as in the previous publication, there was no mention of the use of ai, but cuijpers believes that few if any of the studies reviewed in his publication used ai (p. cuijpers, personal communication, march , ) . there is an emerging area of the use of ai in treatment that is informative. tuerk et al. ( ) , in a special section of current psychiatry reports focusing on psychiatry in a digital age, describe several approaches to using technology in evidence-based treatments. most relevant is their discussion of the use of ai in what has been called "conversational artificial intelligence" where there is a real-time interchange between a computer and a person. they note research that shows that this approach is low risk, high in consumer satisfaction, and high in self-disclosure. they suggest that there is a great deal of clinical potential in using ai in this manner. in a review of the literature from to on conversational agents used in the treatment of mental health problems, gaffney et al. ( ) found only qualifying studies out of an initial , with four being what they called full-scale rcts. they concluded that the use of conversational agents was limited but growing. all studies showed reduced psychological distress, with the five controlled studies showing a significant reduction compared to control groups. however, the three studies that used active controls did not show significant differences between the waitlist controls and use of a conversational agent, although all showed improvement. the authors concluded that the use of conversational agents in therapy looks promising, but not surprisingly, more research is needed. a similar conclusion on conversational agents was reached in another independent review (vaidyam et al. ) . i have little doubt that more research will be forthcoming in this emerging area. in summary, previous research using digital but not aipowered icbt, self-help (bibliotherapy), and ai-powered conversational agents suggests that effective treatment can be delivered without a human clinician under certain circumstances. i want to emphasize that these studies are suggestive but far from definitive. rather, they suggest that the role of the clinician is worth more exploration, but they do not establish the conclusion that we do not need clinicians to deliver services. we need to know a great deal more about how ai-supported therapy operates in different contexts. a survey of psychiatrists from countries asked about how technology will affect their future practice (doraiswamy et al. ) . only . % felt their jobs would become obsolete, and only a small minority ( %) felt that ai was likely to replace a human clinician in providing care. as much of the literature on the effects of ai on jobs suggests, those surveyed believed that ai would help in more routine tasks such as record keeping ( %) and synthesizing information, with about % believing their practices would be substantially changed. about % thought ai would have no influence or only minimal effect on their future work over the next years. another % thought their practices would be moderately changed by ai over the next years. more than three quarters ( %) thought it unlikely that technology would ever be able to provide care as well as or better than the average psychiatrist. only % of u.s.-based psychiatrists predicted that the potential benefits of future technologies or ai would outweigh the possible risks. some of the specific tasks that psychiatrists typically perform, including mental status examination, evaluation of dangerous behavior, and the development of a personalized treatment plan, were also felt to be tasks that a future technology would be unlikely to perform as well. i do not think many psychiatrists in this study are prepared for the major changes in their practices that are highly likely to occur in the next quarter century. in a thoughtful essay on the future of digital psychiatry, hariman et al. ( ) draw a number of conclusions. they predict major changes in practice, with treatment by an individual psychiatrist alone becoming rare. patients will receive treatment through their phones, participate in videoconferencing, and converse with chatbots. clinicians will receive daily updates on the patients through remote sensing devices and self-report. ai will be involved in both diagnosis and treatment and will integrate diverse sources of information. concerns over privacy and data security will increase. this is not the picture that the previously described survey of psychiatrists anticipated. brown et al. ( ) present the pros and cons of ai in an interesting debate format. on the pro side, the authors argue that while there are current limitations, the improvements in natural language processing (nlp) will lead to better clinical interviews. they point to research that shows people are more likely be honest with computers as a plus in obtaining more valid information from clients. they expect the ai "clinician" will be seen as competent and caring. they do note the danger that non-transparent ai will produce unintended negative side effects. those arguing against the use of ai clinicians acknowledge the technical superiority of ai to accomplish more routine tasks such as information gathering and tracking, but they point out the limitations even in the development of ai therapists. the lack of data needed to develop and test algorithms is critical. i have noted this in the discussion of the diagnostic muddle as a problem that ai can help solve, but these anti-ai authors argue that because psychiatrists disagree on diagnoses, there is no gold standard against which to measure the validity of ai models. this seems to be a rather unusual perspective from which to challenge change. they insightfully note that ai is different from human intelligence and does not perform well when presented with data that are different from training data. but the anti-ai authors acknowledge that more and better data may lead to improvement. brown et al. ( ) argue that common sense is something that ai cannot draw on; however, this seems to be a weak argument when common sense has been demonstrated to be inaccurate under many situations. they conclude with the statement that psychiatry "will always be about connecting with another human to help that individual" (p. ). this may be more wishful thinking than an accurate prediction about the future. those arguing the pro position state that the "the advance of ai psychiatry is inexorable" (p. ). on the other hand, the opponents of ai correctly point out that there is not yet sufficient evidence to draw a conclusion about the effectiveness of ai versus human clinicians. while there is disagreement about the potential advantages and disadvantages of ai, both sides agree that we need more and better research in this area. simon and yarborough ( ) present the case that ai should not be a major concern for mental health. they argue that ideally, our field would abandon the term artificial intelligence in regard to actual diagnosis and treatment of mental health conditions. using that term raises false hopes that machines will explain the mysteries of mental health and mental illness. it also raises false fears that all-knowing machines will displace human-centered mental health care. big data and advanced statistical methods have and will continue to yield useful tools for mental health care. but calling those tools artificially intelligent is neither necessary nor helpful. (p. ) the authors further take the position that despite the buildup around artificial intelligence, we need not fear the imminent arrival of "the singularity," that science fiction scenario of artificially intelligent computers linking together and ruling over all humanity. . . a scenario of autonomous machines selecting and delivering mental health treatments without human supervision or intervention remains in the realm of science fiction. (p. ) a more balanced approach to the role to the issue of replacement of clinicians by ai is presented by ahuja ( ) . after his review of the literature on medical specialists who may be replaced or more likely augmented by ai, his pithy take on this question is "or, it might come to pass that physicians who use ai might replace physicians who are unable to do so" (ahuja , p. ) . clearly, ai research will have to provide strong evidence of its effectiveness before ai will be accepted by some in the psychiatric community. there are several pressing questions about how mental health services should be delivered and about the future of mental health services. doubts about how much clinicians contribute to outcomes, our seeming inability to differentiate the effectiveness among clinicians except at the extremes, the lack of stability of employment of most community based clinicians, the poor track record on implementation of evidence-based programs, the cost of human services, the very limited availability of services especially where resources are inadequate-all lead to strong doubts about continuing the status quo of using clinicians as the primary way in which mental health services are delivered. in contrast, alternative approaches have many advantages. if scaled, ai therapists could be available to patients / and would not be bound to office hours. these ai therapists could represent any demographic or therapy style (e.g., directive) that the client preferred or that had been found to be more effective with a particular client. they can be specialists in any area for which there is sufficient research. in other words, not only can a personalized treatment plan be developed, but a personalized clinician (avatar) can be constructed for the best match with the client. of course, all these are putative advantages. as noted earlier, the application of ai is not without its risks and challenges, especially in putting together the interdisciplinary teams needed to accomplish this research. while i am optimistic about the potential contribution of ai to mental health services, it is just that-a potential. extensive research will be needed to learn whether these approaches produce positive outcomes when compared to traditional face-to face treatment, while also dealing with the ethical issues raised by ai applications. moreover, the quality of research needs significant improvement if we are going to have confidence in the findings. however, as exemplified by the rapid and uncontrolled growth of therapy apps, the world may not wait for rigorous supporting research before adopting a larger role for ai in mental health services. while my brief summaries of findings of ai in the medical literature are supportive of the application of ai, i do not want to give the impression that these positive findings are accepted uncritically. a deeper reading of many of these studies exposes methodological flaws that temper enthusiasm. for example, in reviewing comparisons between healthcare professionals and deep learning algorithms in classifying diseases of all types using medical imaging, x. liu et al. ( a) conclude that the ai models are equivalent to the accuracy of healthcare professionals. this review is the first to compare the diagnostic accuracy of deep learning models to health-care professionals; however, only a small number of the studies were direct comparisons. the authors also caution us by indicating what they labeled as the poor quality of many of the studies. the problems included low external validity (not done in a clinical practice setting), insufficient clarity in the reporting of results, lack of external validation, and lack of uniformity of metrics of diagnostic performance and deep learning terminology. however, the authors were encouraged by improvement in quality in the most recent studies analyzed. in commenting on the study, cook ( ) noted other limitations and concluded that it is premature to draw conclusions about the comparative accuracy of ai versus human physicians. if we are not more cautious, she warns that we will experience "inflated expectations on the gartner hype cycle" (p. e ). the latter refers to the examination of innovations and trends in ai. she cautions us to "stick to the facts, rather than risking a drop into the trough of disillusionment and a third major ai winter" (p. e ). many issues are raised in cook's paper, and the need to avoid the hype often found in the ai field is reiterated in the national academy of medicine's monograph on the use of ai in healthcare (matheny et al. ) . mental health services are changing. there are more than , mental health apps on the internet that are being used without much evidence of their effectiveness (marshall et al. ; bergin and davis ; gould et al. ) . the explosion of mental health apps is the leading edge of future autonomous interventions. however, there is pressure to bring some order to this chaos. probably the next innovation that will involve ai is its use in stepped therapy in which clients are typically triaged to low-intensity, low-cost care, monitored systematically, and stepped up to more intensive care if progress is not satisfactory . in this schema, the low-cost care could be ai-based apps with little risk to the client. if more confidence is gained in the safety and effectiveness of this type of protocol, the use of ai-based treatment would be expected to increase. the covid- pandemic will produce a major impact on mental health services. first, it is expected that the stresses caused by the pandemic will increase the demand for services (qiu et al. ; rajkumar ) . already poorly resourced mental health systems will not be able to meet this demand (Ćosić et al. ; ho et al. ; holmes et al. ) , especially in low resourced countries. however, the biggest change will be in the service delivery infrastructure. because of social distancing requirements, in-person delivery of therapy is being severely curtailed. while the major change at this time appears to be a shift to telemedicine (shore et al. ; van daele et al. ) , which is being adopted across almost all healthcare, there will need to be changes instituted in how clinicians are trained and supervised (zhou et al. ) . i have little doubt that ai will be adopted in order to increase efficiency and address the change in the service environment caused by the pandemic. in addition to changes initiated by the pandemic, there appear to be some changes in funding as a result of the protests concerning george floyd's killing. there is reconsideration of shifting some funding from police services to mental health and conflict reduction services to be delivered by personnel outside law enforcement (stockman and eligon ) . it will be difficult to meet this potential demand using the current infrastructure. the literature on ai and medicine is replete with warnings about the difficulties we face in integrating ai into our healthcare system. as a program evaluator, i appreciate the position paper describing the urgent need for well-designed and competently conducted evaluations of ai interventions as well as the guidelines provided by magrabi et al. ( ) . more suggestions for improving the quality of research on supervised machine learning can be found in the paper by cearns et al. ( ) . celi et al. ( ) describe the future in a very brief essay that is worth quoting: clinical practice should evolve as a hybrid enterprise with clinicians who know what to expect from, and how to work with, what is fundamentally a very sophisticated clinical support tool. working together, humans and machines can address many of the decisional fragilities intrinsic to current practice. the human-driven scientific method can be powerfully augmented by computational methods sifting through the necessarily large amounts of longitudinal patientand provider-generated data. (p. e ) however, research on ai, data science, and other technologies is in its infancy if not the embryonic stage of development. i am fully immersed in the struggle to implement several types of technologies in practice. changing the routine behavior of clinicians and clients is a major barrier to using new technologies, regardless of the effectiveness of these approaches. emanuel and wachter ( ) argue that the most important problem facing healthcare is not the absence of data or analytic approaches but turning predictions and findings into successful accomplishments through behavior change. alongside the investment in technology and analytics, we need to support the research and applications of psychologists, behavioral economists, and those working in the relatively new field of translational and implementation research. the emphasis on practical and implementable digital approaches requires a methodology that departs from the traditional efficacy approach, which does not focus on context and thus is difficult to translate to the real world. mohr et al. ( ) suggest a solution-based approach that focuses on three stages that they label create, trial and sustain. creation focuses on the initial stages of development, although not exclusively, and takes advantage of the unique characteristics of digital approaches that focus on engagement rather than trying to mimic traditional psychotherapy. trial must be dynamic because digital technologies rapidly change; rapid evaluations are required, such as continuous quality improvement strategies (bickman and noser ) . sustainability requires more from investigators and evaluators than publication of results; they must also produce sustainable implementation that no longer depends on a research project for support. we are currently in an ai summer in which there are important scientific breakthroughs and large investments in the application of ai (hagendorff and wezel ) . but ai has had several winters when enthusiasm for ai has waned and unreasonable expectations have cooled. we were confronted with the reality that ai could not accomplish everything that people thought it could and that investors and journalists had hyped. ai, at least in the near term, will not be the superintelligence that will destroy humanity or the ultimate solution that will solve all problems. enthusiasm for ai seems to run in cycles like the seasons. ai summers suffer from unrealistic expectations, but the winters bring an experience of disproportionate backlash and exaggerated disappointment. there was a severe winter in the late s, and another in the s and s (floridi ) . today, some are talking about another predictable winter (nield ; walch ; schuchmann ). floridi ( ) suggests that we can learn important principles from these cycles. first is whether ai is going to replace previous activities as the car did with the buggy, diversify activities as the car did with the bicycle, or complement and expand them as the plane did with the car. floridi asks how acceptable an ai that survives another winter will be. he suggests that we need to avoid oversimplification and think deeply about with we are doing with ai. in the june issue of the technology quarterly of the economist ( ), it is suggested that because ai's current summer is "warmer and brighter" than past ones because of widespread deployment of ai, "another fullblown winter is unlikely. but an autumnal breeze is picking up" (p. ). i have traced a path my career has taken from an almost exclusive focus on randomized experiments to consideration of the applications of ai. i have identified the main problems related to mental health services research's almost sole dependence on rct methodology. i have linked the problems with this methodology with the lack of satisfactory progress in developing sufficiently effective mental health services. the recent availability of ai and the value now being placed on precision medicine have produced the early stages of a revolution in healthcare that will determine how treatment will be developed and delivered. i anticipate that in the very near future, a first-year graduate student will be contemplating the same questions that i raised years ago, because they are still relevant, but this time he or she will realize that there are answers that were not available to me. acknowledgements this paper is part of a special issue of this journal titled "festschrift for leonard bickman: the future of children's mental health services." the issue includes a collection of original children's mental health services research articles, this article, three invited commentaries on this article, and a compilation of letters in which colleagues reflect on my career and on their experiences with me. the word festschrift is german and means a festival or celebration of the work of an author. there are many people to thank for their assistance in both the festschrift and this paper. first, i want to acknowledge my two colleagues and friends, nick ialongo and michael lindsey, who spontaneously originated the idea of a festschrift during a phone conversation with them. the folks at the johns hopkins bloomberg school of public health were great in supporting the daylong event held on may , . the many friends, family, former students and colleagues who traveled from around the country to attend and present made the event memorable. i am grateful to the committee that helped put this special issue together, which included marc atkins, catherine bradshaw, susan douglas, nick ialongo, kim hoagwood, and sonja schoenwald. this paper represents more than a yearlong effort for which many contributed including the scholars who provided email exchanges and ideas throughout the conceptualization and writing process. i thank the two editors of this special issue, sonja and catherine, who spent much of their valuable time on this project during a very difficult period. the manuscript was greatly improved through the efforts of my copy editor, diana axelsen. most of all i thank corinne bickman, who has been my partner in life for almost years and has managed this journal since its inception. without her support and love none of this would have been possible. funding no external funding was used in the preparation or writing of this article. conflict of interest from the editors: leonard bickman is editorin-chief of this journal and thus could have a conflict of interest in how this manuscript was managed. however, the guest editors of this special issue, entitled "festschrift for leonard bickman: the future of children's mental health services," managed the review process. three independent reviews of the manuscript were obtained and all recommended publication with some minor revisions, with which the editors concurred. while the reviewers were masked to the author, because of the nature of the manuscript is was not possible to mask the author for the reviewers. from the author: the author reported receipt of compensation related to the peabody 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alliance really therapeutic? revisiting this question in light of recent methodological advances major developments in methods addressing for whom psychotherapy may work and why key: cord- -l wjwn authors: fiorillo, andrea; sampogna, gaia; giallonardo, vincenzo; del vecchio, valeria; luciano, mario; albert, umberto; carmassi, claudia; carrà, giuseppe; cirulli, francesca; dell’osso, bernardo; nanni, maria giulia; pompili, maurizio; sani, gabriele; tortorella, alfonso; volpe, umberto title: effects of the lockdown on the mental health of the general population during the covid- pandemic in italy: results from the comet collaborative network date: - - journal: european psychiatry : the journal of the association of european psychiatrists doi: . /j.eurpsy. . sha: doc_id: cord_uid: l wjwn background: the coronavirus disease (covid- ) pandemic is an unprecedented traumatic event influencing the healthcare, economic, and social welfare systems worldwide. in order to slow the infection rates, lockdown has been implemented almost everywhere. italy, one of the countries most severely affected, entered the “lockdown” on march , . methods: the covid mental health trial (comet) network includes italian university sites and the national institute of health. the whole study has three different phases. the first phase includes an online survey conducted between march and may in the italian population. recruitment took place through email invitation letters, social media, mailing lists of universities, national medical associations, and associations of stakeholders (e.g., associations of users/carers). in order to evaluate the impact of lockdown on depressive, anxiety and stress symptoms, multivariate linear regression models were performed, weighted for the propensity score. results: the final sample consisted of , participants. among them, . % of respondents (n = , ) reported severe or extremely severe levels of depressive symptoms, . % (n = , ) of anxiety symptoms and . % (n = , ) reported to feel at least moderately stressed by the situation at the dass- . according to the multivariate regression models, the depressive, anxiety and stress symptoms significantly worsened from the week april – to the week april to may (p < . ). moreover, female respondents and people with pre-existing mental health problems were at higher risk of developing severe depression and anxiety symptoms (p < . ). conclusions: although physical isolation and lockdown represent essential public health measures for containing the spread of the covid- pandemic, they are a serious threat for mental health and well-being of the general population. as an integral part of covid- response, mental health needs should be addressed. there is no doubt that the coronavirus disease (covid- ) pandemic, and its related containment measures such as lockdown, is affecting mental health of the general population worldwide [ ] [ ] [ ] . this is an unprecedented event, which is influencing the healthcare, political, economic, and social systems [ ] . given the high level of contagiousness, as well as the lack of appropriate treatments and vaccines, almost all countries have adopted confinement measures, including lockdown, home isolation and physical distancing [ ] . while most of the clinical and research efforts have been directed to reduce the effects of the virus on physical health [ ] [ ] [ ] , its short-and long-term effects on mental health are causing a second wave of pandemic, which has been mostly neglected [ ] [ ] [ ] . furthermore, the pandemic represents a traumatic event which has differential effects at individual and population levels. at the individual level, high rates of depression, anxiety, fear, panic, anger, and insomnia have been documented in studies mainly carried out in china or from short-term reports [ ] [ ] [ ] . at the population level, the pandemic is associated with a range of psychosocial adversities, including economic hardship and financial losses (due to unemployment and reduced income), school closures, inadequate resources for medical response, domestic violence, and deficient distribution of basic good necessities [ ] . the psychopathological consequences include the fear of contracting the disease and of dying, losing livelihoods and loved ones, uncertainty and worries about the future, social discrimination, and separation from families and caregivers [ ] [ ] [ ] [ ] . this is why the current pandemic represents a new, complex and multifaceted form of psychosocial stressor [ ] , being completely different from other natural disasters [ ] , such as earthquakes or tsunamis [ , ] , wars, terroristic attacks, mass conflicts, or economic crisis [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , and also from previous epidemics, such as severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers) and ebola [ , ] . italy has been the first western country heavily affected by the pandemic, and it has been the country with the highest number of infected and dead people for many weeks [ ] . on march , , the italian prime minister has placed million people under lockdown. this measure has been prolonged for weeks, until may , . this period is known as "phase one," during which all not necessary activities have been closed, more than , people have died and almost , people have been homeisolated. during the initial phase of the pandemic, the outbreak in italy seemed to have a greater severity of the disease, with a higher case fatality rate (cfr) than previously observed in china ( . vs. . %) [ ] . the excess in covid- mortality was higher in men than in women living in northern cities versus in central and southern italy (men: + % and + % and women: + % and + %, respectively), with an increasing trend by age [ ] . from may , a gradual reopening of financial and commercial activities has taken place (known as "phase two" of the national sanitary emergency). a few, short-term studies have already shown the impact of lockdown on the mental health of the italian general population in the first days of "phase one" [ ] [ ] [ ] . we have decided to carry out an online survey using several validated assessment instruments in order to evaluate the impact of the lockdown on the mental health of italian population throughout the different weeks of phase one [ ] . in particular, in this paper we aim to: (a) report the levels of depressive, anxiety and stress symptoms in a large sample of the italian general population; (b) explore the levels of depressive, anxiety and stress symptoms during the different weeks of lockdown; and (c) identify possible risk and protective factors for mental health outcome. the covid mental health trial (comet) is a national trial coordinated by the university of campania "luigi vanvitelli" (naples) in collaboration with nine university sites: università politecnica delle marche (ancona), university of ferrara, university of milan bicocca, university of milan "statale", university of perugia, university of pisa, sapienza university of rome, "catholic" university of rome, university of trieste. the center for behavioral sciences and mental health of the national institute of health in rome has been involved in the study by supporting the dissemination and implementation of the project according to the clinical guidelines produced by the national institute of health for managing the effects of the covid- pandemic. the comet trial includes three phases: phase one consists in the dissemination of a survey on the impact of lockdown and its related containment measures on the mental health of the italian general population; the second phase consists in the development of a new psychosocial online supportive intervention [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for the management of the consequences on mental health of the pandemic; the last phase consists in the evaluation of the efficacy and feasibility of the experimental psychosocial intervention in a randomized control trial. the results of phase are described in this paper. the study has been approved by the ethical review board of the coordinating center (protocol number: /i). the primary outcome of the study is the severity of depressive-anxiety symptoms evaluated with the depression, anxiety, stress scale (dass- ) [ ] . secondary outcomes include the levels of global mental health status, of obsessive-compulsive and post-traumatic symptoms, presence and severity of insomnia, the levels of perceived loneliness and the presence of suicidal ideation/suicidal thoughts. furthermore, exploratory variables include coping strategies, levels of post-traumatic growth, perceived social support and resilience. the dass- evaluates the general distress on a tripartite model of psychopathology [ ] and is a reliable and valid measure in assessing mental health in the general population [ ] , which has been already adopted in previous research on sars [ ] and covid- [ , ] . the dass consists of items grouped in three subscales: depression, anxiety, and stress. each item is rated on a -level likert scale, from (never) to (almost always). the total score is calculated by adding together the response values of each item, with higher scores indicating more severe levels of depressive, anxiety, and stress symptoms. the score at the dass-depression subscale (e.g., "i felt that i had nothing to look forward to") is divided into normal ( - ), mild ( ) ( ) ( ) , moderate ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , severe ( ) ( ) ( ) ( ) ( ) ( ) ( ) , and extremely severe depression ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the score at the dass-anxiety subscale (e.g., "i was worried about situations in which i might panic and make a fool of myself") is divided into normal ( - ), mild ( - ), moderate ( ) ( ) ( ) ( ) ( ) , severe ( ) ( ) ( ) ( ) ( ) , and extremely severe anxiety . the score at the dass-stress subscale (e.g., "i tended to over-react to situations") is divided into normal ( - ), mild ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , moderate ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , severe ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , and extremely severe stress ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the general health questionnaire (ghq)- items version explores participants' mental health status through six positively worded items (e.g., "have you been able to concentrate"?) and six negatively worded items (e.g., "have you lost much sleep over worry?"). the standard scoring method recommended by goldberg for the need of case identification is called "ghq method." scores for the first two types of answers are " " (positive) and for the other two are " " (negative). threshold ≥ at ghq identifies people with a probability > % of having a mental health problem [ ] . the obsessive-compulsive inventory-revised version (oci-r) consists of items rated on a -level likert scale, ranging from to . the total score is calculated by adding all single items. scores above the threshold of are indicative of an ocd diagnosis [ ] . the insomnia severity index (isi) includes seven items rated on a -level likert scale (from to ), with a total score ranges from to [ ] . the suicidal ideation attributes scale (sidas) consists of five items assessing frequency, controllability, closeness to attempt, level of distress associated with suicidal thoughts and impact on daily functioning. each item is assessed on a -level likert scale, with a total score ranging from to . in case of scoring " -never" to the first item, all other items are skipped, and the total score is zero. the presence of any suicidal ideation is considered indicative of risk for suicidal behavior, while a cut-off of is used to indicate high risk of suicidal behavior [ ] . the severity-of-acute-stress-symptoms-adult scale (sass), which consists of nine items rated on a -point scale (from = not at all to = extremely), has been used to assess the presence of traumatic stress symptoms. the total score ranges from to , with higher scores indicating a greater severity of acute stress disorders [ ] . the impact of event scale (ies)-short version measures the traumatic reactions in people who have experienced traumatic events. each item is rated on a -point scale ranging from (not at all) to (often). the ies evaluates the dimensions of intrusion, avoidance, and alteration in arousal [ ] . the ucla loneliness scale-short version is an eight-item scale designed to measure subjective feelings of loneliness, as well as feelings of social isolation. each item is scored on a -level likert scale from = never to = often [ ] . the brief-cope consists of items grouped in subscales [ ] . each item is rated on a -level likert scale from = "i have not been doing this at all" to = "i have been doing this a lot." coping strategies are divided in maladaptive strategies, including denial, venting, behavioral disengagement, self-blame, self-distraction and substance abuse, and adaptive coping strategies, which include emotional support, use of information, positive reframing, planning and acceptance. two other subscales include religion and humour. the short form of post-traumatic growth inventory (ptgi) is a -item assessment instrument grouped into five dimensions: relating to others, new possibilities, personal strengths, spiritual change, and appreciation of life. items are rated on a -point likert scale, from = "i did not experience this change as a result of my crisis" to = "i experienced this change to a very great degree as a result of my crisis". higher scores indicate higher levels of post-traumatic growth [ ] . the connor-davidson resilience scale (cd-risc), which includes items rated on a -level likert scale, is subdivided into the following five factors: (a) personal competence, high standards, and tenacity; (b) trust in one's instincts, tolerance of negative affect, and strengthening effects of stress; (c) positive acceptance of change and secure relationships; (d) control; and (e) spiritual influences. higher values indicate higher levels of resilience [ ] . the multidimensional scale of perceived social support (mspps) consists of items rated on a level-likert scale, from = "absolutely false" to = "absolutely true". items are grouped into three dimensions: family support, support by friends and support by significant others. higher values correspond to higher levels of perceived support [ ] . the maslach burnout inventory (mbi) has been used to evaluate the levels of burn-out in medical personnel [ ] . data regarding healthcare professionals are not included in this paper since they are out of the aims of the study and will be reported in subsequent analyses. respondents' socio-demographic (e.g., gender, age, geographical region, working and housing condition, etc.) and clinical information (e.g., having a previous physical or mental disorder, using illicit drugs or medications, etc.) have been collected through an ad-hoc schedule. the phase one of the comet trial consists in an online survey carried out between march and may in the italian adult population. the survey has been implemented through a multistep procedure: (a) email invitation to healthcare professionals and their patients; (b) social media channels (facebook, twitter, instagram); (c) mailing lists of universities, national medical associations and associations of stakeholders (e.g., associations of users/carers); and (d) other official websites (e.g., healthcare or welfare authorities websites). the online survey has been set up through eusurvey, a web platform promoted by the european commission ( ). the survey has been officially launched on march , , and it takes approximately min (range - min) to be completed. the full study protocol is available elsewhere [ ] . descriptive statistics were performed in order to describe the sociodemographic and clinical characteristics of the sample. the time points of data collection were recorded and coded using the variable "week" . therefore, geographical regions of respondents were recoded using a binary variable "severely impacted area." this variable has been entered in the regression model in order to evaluate the direct impact of living in an area with a higher risk of being infected rather than the impact of geographical area per se. we hypothesized that individuals living in the most affected areas should have presented more severe symptoms compared with those living in less affected areas. by order of the italian health authority, persons subject to quarantine are forbidden to move from home or residence for days, with the aim to separate persons exposed (or potentially exposed) to the infectious agent from the general community for reducing the contagion rate. people who have been subjected to those restrictions were coded using the binary variable "quarantine." in order to adjust for the likelihood of participants of being exposed to covid infection in each week, a propensity score was calculated [ ] . this methodological choice was due to the fact that the propensity score produces a better adjustment for differences at baseline, rather than simply including potential confounders in the multivariable models. the propensity score was calculated using as independent variables age, gender, socioeconomic status and living in a severely impacted area [ ] . in the final regression model, the inverse probability weights, based on the propensity score, were applied in order to model for the independence between exposure to the infection, outcomes and estimation of causal effects. in order to evaluate factors associated with the severity of depressive, anxiety and stress symptoms at dass- (primary outcomes), multivariate linear regression models were performed, including as independent variables: being infected by covid- , having a pre-existing mental disorder, being a healthcare professional. furthermore, in order to evaluate the impact of the duration of lockdown and of other related containment measures on the primary outcomes, the categorical variable "week" was also entered in the regression models. the models were adjusted for the rate of new covid cases and of covid-related mortality during the study period, as well as for several socio-demographic characteristics, such as gender, age, occupational status, having a physical comorbid condition, hours spent on internet, levels of perceived loneliness, health status, number of cohabiting people, level of satisfaction with one's own life, with cohabiting people, with the housing condition. missing data have been handled using the multiple imputation approach [ ] . statistical analyses were performed using the statistical package for social sciences (spss), version . and stata, version . for all analyses, the level of statistical significance was set at p < . . the final sample consisted of , participants, % female (n = , ), with a mean age of . ( . ) years; half of respondents were in a stable relationship, living with the partner ( . %, n = , ) ( table ). the vast majority of participants were employed ( . %, n = , ) and . % (n = , ) shifted to smart working during the pandemic. (n = , ) of respondents lost their job during the pandemic. % spent more time on internet than usual, more frequently for instant messaging ( . %, n = , ), searching for information ( . %, n = , ), or using social networks ( . %, n = , ). about . % of cases (n = , ) suffered from a pre-existing physical illness, mainly cardiovascular diseases ( . %), osteo-articular disorders ( . %), thyroid dysfunctions ( %), and diabetes/dyslipidaemia ( . %). . % (n = , ) reported to have a pre-existing mental disorder, more frequently anxiety ( . %) and depressive disorders ( . %). % of respondents (n = , ) were healthcare professionals. almost all participants ( . %, n = , ) scored above the threshold of at the ghq, indicating the risk of having any mental health problem. in particular, depressive symptoms were moderate in . % of respondents (n = , ) and severe or extremely severe in . % (n = , ); anxiety symptoms were moderate in . % (n = , ) of respondents and severe or extremely severe in . % (n = , ); stress symptoms were at least moderate in . % (n = , ) ( table ) . moderate to severe levels of insomnia were found in . % of respondents (n = , ). about . % (n = , ) of the sample scored above the threshold for clinical relevance of obsessivecompulsive symptomatology, with a global severity of obsessivecompulsive symptoms of . (ae . ) at oci-r. suicidal ideation is reported by . % (n = , ) of the sample, with a mean score of . ( . ) at the sidas. participants showed high levels of avoidance and hyperarousal symptoms ( . ae . and . ae . , respectively), with lower levels of intrusive symptoms ( . ae . ) at the ies-r. . % (n = , ) reported to feel alone, . % (n = , ) to feel excluded by others and . % (n = , ) feel that "other people are around them, but not together with them", at the ucla. at the brief-cope, we found that respondents more frequently used adaptive coping strategies, such as planning ( . % of participants, n = , ), acceptance ( . %, n = , ), and active coping ( . %, n = , ). as regards maladaptive coping strategies, . % (n = , ) of the sample used venting, % (n = , ) self-blame and . % (n = , ) self-distraction. moreover, a relatively high proportion of respondents ( . %; n = , ) reported to use psychoactive medications in order to cope with the situation. at the ptgi, participants reported that they found "something positive" out of this situation, with high levels of "appreciation for life" ( . %, n = , ), feeling closer to other people ( . %, n = , ), being more satisfied of everyday life ( . %, n = , ) and increased ability to handle difficult situations ( . %, n = , ). furthermore, respondents reported a good level of resilience with a mean score of . ae . at the cd-risc. finally, the majority of participants declared to feel supported by family ( . %, n = , ) and friends ( . %, n = , ), with a mean score of . ae . at the mspps family support subscale and of . ae . at the mspps friend support subscale (table ) . the levels of depressive symptoms increased over the period of the lockdown. in particular, depressive symptoms changed from . ae . in the week march to april to . ae . in the week april to may (p < . ). anxiety symptoms increased from . ae . in the week march to april to . ae . in the week april to may (p < . ). furthermore, the levels of stress symptoms increased from . ae . in the week march to april to . ae . in the week april to may (p < . ). these increases were higher in female participants compared to males (figures - ; p < . ). the multivariate regression analyses are reported in table . according to the multivariate regression models, weighted for the propensity score, weeks of exposure to the pandemic and to the related containment measures were significantly associated with worsening of depressive symptoms, with beta coefficient ranging from . ( % confidence interval, ci: . - . protective factors against the development of psychiatric symptoms included higher levels of satisfaction with one's own life and with cohabiting people, and living with a higher number of family members (p < . ). the comet is the first trial evaluating the global impact of the covid- pandemic and its related containment measures on several dimensions of mental health in a large sample of the italian population. one of our main findings is the presence of moderate to severe levels of depressive, anxiety, and stress symptoms which are higher than those found in china [ , , ] . this difference could be due to the type of immediate health response in the two countries, with clear lockdown measures from the beginning of the pandemic in china [ ] and a more fragmented preventive approach in italy, which may have increased the levels of fears and uncertainty in this country [ ] [ ] [ ] ] . in fact, the uncertainties about the pandemic progression, the "hypochondriac concerns" [ ] and fear that the epidemic is difficult to control represent triggering factors for the development of mental health problems [ , ] . moreover, studies carried out during natural disasters, war, fires and terroristic attacks found high levels of depressive/anxiety-related symptoms in the general population [ ] [ ] [ ] [ ] [ ] [ ] [ ] , but nevertheless they were significantly lower compared to those we found in our study. these data confirm that the current pandemic is an unprecedented event in terms of its impact on the mental health of the general population. a second interesting finding of our survey is that the levels of anxiety, depressive and stress symptoms increased over time, being more severe in the last weeks of the lockdown, as also found in our regression models controlled for all socio-demographic characteristics of respondents. this finding confirms the hypothesis that the duration of containment measures significantly influences mental health and well-being of the general population, as also found by sibley et al. [ ] in a sample of the general population in new zealand. moreover, this trend has not been influenced by the rate of covid cases and covid mortality rates in italy, highlighting that these public measures-although being necessary for infection control-should be removed as soon as possible in order to safeguard public mental health. female participants are at higher risk of developing depressiveanxiety symptoms, as already shown in small italian samples [ , ] and in previous outbreaks [ ] . this finding can be due to the higher incidence in women of anxiety-depressive disorders [ ] [ ] [ ] [ ] and of anxious, cyclothymic and depressive temperaments in women [ ] , also in community-based samples [ ] . moreover, being affected by a pre-existing mental health problem represents an independent significant risk factor for the development of depressive, anxiety and stress symptoms, as already reported by plunkett et al. [ ] and hao et al. [ ] . this finding suggests the need to provide as soon as possible adequate and tailored supportive interventions to mentally ill patients, who represent fragile and at-risk individuals that have been overlooked during the initial phases of the pandemic [ ] [ ] [ ] [ ] [ ] . during the lockdown participants reported an increased time spent on internet, which was associated with a higher risk of developing mental health problems, thus not confirming our hypothesis of a protective effect played by internet on mental health. this finding may be due to the diffusion through internet of uncontrolled and unreliable information and fake news, which may have increased the levels of anxiety and depressive symptoms in people who are alone and with lower levels of education [ ] . this finding highlights the need for media professionals to receive an appropriate training, in order to provide unbiased and nonsensationalistic information during catastrophic events. being unemployed, retired or housewife was significantly associated with higher levels of anxiety-depressive symptoms [ ] . in the uk, belonging to a socio-economic disadvantaged group increased the risk of developing mental health problems, according to a gradient across the different weeks of the lockdown [ ] . this finding highlights the need for global, multi-level socio-economic initiatives aiming to reduce the negative effect of the pandemic on the society [ ] . these data should also be interpreted considering the high rate ( . %) of suicidal ideation/suicidal thoughts found in our sample. the rate of suicidal ideation found in our sample is quite impressive, compared with the % found in a previous epidemiological study carried out in italy [ ] . several factors may contribute to the increased rate of suicidal ideation in the italian general population, including uncertainty about the future, loneliness, physical distancing, unemployment, economic recession and interpersonal violence [ ] . all these risk factors should be taken into account in the implementation of actions aiming to prevent suicide [ ] [ ] [ ] . participants reported several disturbances in sleep quality and patterns, as already found in other studies carried out in china and in other european countries [ , ] . the public health containment measures implemented worldwide have markedly changed daily routines and may have had an impact on sleep pattern and on the risk of developing other mental health problems [ , ] . in order to develop tailored innovative preventive and/or therapeutic strategies, the specific socio-demographic and clinical predictors of sleep problems should be identified. finally, good levels of perceived social support and of posttraumatic growth in the aftermath of the pandemic have been reported from the italian general population participating in our survey. it may be that the italian socio-cultural context, with strong family ties and social relationships, may have positively impacted on the perception of mutual social support [ ] . however, longitudinal studies may help to evaluate changes in the levels of posttraumatic growth, resilience, and social support in the subsequent phases of the ongoing health crisis [ ] . our study has several strengths. this is the first study carried out in different geographic italian regions with a large sample from the general population during the lockdown period. validated and reliable assessment instruments have been used in order to investigate several domains of mental health and psychological wellbeing according to a propensity score analysis. moreover, as primary outcome we have selected the same assessment tool (the dass- ) used in studies carried out in china in order to allow direct comparisons between the two countries. although the dass- scores in the italian general population prior of the pandemic are not available, the comparison of our findings with national statistics (https://www.epicentro.iss.it/mentale/epidemiologia-italia) document higher levels of anxiety, depressive and stress symptoms during the pandemic. therefore, the increased frequency of depressive-anxiety symptoms in our sample could be interpreted as covid- related, although this causal association should be further investigated. in any case, we believe that the analysis of dass- over the different weeks of lockdown provide an important contribution to the field in order to clarify the direct impact of the pandemic on the mental health. we are aware that the use of an online tool is not the best methodological choice, since it may have excluded elderly people or those living in socially disadvantaged contexts [ ] . however, this choice was necessary in order to reach a large portion of italian population in a short time and in a pandemic situation, when faceto-face contacts are forbidden [ ] . finally, it must be acknowledged that collected data are related to depressive or anxiety symptoms, which cannot be considered as sufficient to formulate a diagnosis of depressive/anxiety disorders. therefore, this survey represents an initial step for the promotion of appropriate screening procedures in the general population for the early detection of full-blown mental disorders. the present study has several clinical implications: (a) to promote mass screening campaigns for the general population in order to identify the presence of subthreshold mental disorders; (b) to disseminate informative intervention on how to deal with the mental health consequences of the pandemic; and (c) to support at-risk population-mainly people with pre-existing mental health problems and covid- patients-with tailored innovative psychosocial interventions. in conclusion, there is the need to address mental health needs as an integral part of covid- response. in fact, although physical isolation and lockdown represent essential public health measures for containing the spread of the covid- pandemic, they are a serious threat for mental health and well-being of the general population. it is necessary to get prepared if a next emergency will come, in order to provide appropriate community-based mental health service responses to the population. financial support. this research received no specific grant from any funding agency, commercial or not-for-profit sectors. conflicts of interest. the authors have no conflicts of interest to disclose. data availability statement. the dataset is not available for sharing. ethical standards.the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of , as revised in . the ethical review board of the university of campania "l. vanvitelli" has approved the study. the consequences of the covid- pandemic on mental health and implications for clinical practice psychological adjustment 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social research . : virtual snowball sampling method using facebook says who? the significance of sampling in mental health surveys during covid- key: cord- -knlc bxh authors: holmes, emily a; o'connor, rory c; perry, v hugh; tracey, irene; wessely, simon; arseneault, louise; ballard, clive; christensen, helen; cohen silver, roxane; everall, ian; ford, tamsin; john, ann; kabir, thomas; king, kate; madan, ira; michie, susan; przybylski, andrew k; shafran, roz; sweeney, angela; worthman, carol m; yardley, lucy; cowan, katherine; cope, claire; hotopf, matthew; bullmore, ed title: multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science date: - - journal: lancet psychiatry doi: . /s - ( ) - sha: doc_id: cord_uid: knlc bxh the coronavirus disease (covid- ) 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- 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, . 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- pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with covid- . 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- . 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. it is already evident that the direct and indirect psychological and social effects of the coronavirus disease (covid- ) 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. , furthermore, severe acute respiratory syndrome coronavirus (sars-cov- ), the virus that causes covid- , might infect the brain or trigger immune responses that have additional adverse effects on brain function and mental health in patients with research funders and researchers must deploy resources to understand the psychological, social, and neuroscientific effects of the covid- pandemic. mob ilisation 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- 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 smallscale 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 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- 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 ). the general population survey, done by ipsos mori, 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- 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- on the mental health of family members, especially children and older people. both surveys are reported online. 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. in this section, we focus on the psychological processes and effects in individual people related to covid- , such as cognition, emotion, and behaviour, that affect mental health (table ) . 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 selfharm) will increase. of note, however, is that a rise in suicide is not inevitable, especially with national mitigation efforts. 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 was associated with a % increase in suicide in those aged years and older; around % of recovered patients remained anxious; and % of health-care workers experienced probable emotional distress. [ ] [ ] [ ] patients who survived severe and life-threatening illness were at risk of post-traumatic stress disorder and depression. , many of the anticipated consequences of quarantine 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). [ ] [ ] [ ] a major adverse consequence of the covid- pandemic is likely to be increased social isolation and loneliness (as reflected in our surveys), which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan. , 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 this position paper summarises the priorities put forward by an interdisciplinary group of 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, . 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 (covid- ) 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, people completed the survey, submitting concerns about the mental health effects of the covid- pandemic and 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- on mental wellbeing and what is helping people's mental wellbeing at this time. in total, interviews were completed with adults aged between and 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 % confidence interval unless stated otherwise. a summary report of the findings of both surveys and further methodological details can be found online. the ipsos mori tabular data can be found on its website. 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- on mental health and coping strategies within the very short timeframe. problems. , social isolation and loneliness are distinct and might represent different risk pathways. to inform management of covid- , 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. , 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. 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. , techniques assessing moment to moment changes in psychological risk factors should be embraced. given the unique circumstances of covid- , data will be vital to determine causal mechanisms associated with poor mental health, , including loneliness and entrapment. to optimise effectiveness of psychological treatments, they need to be mechanistically informedthat is, targeting factors which are both causally associated with poor mental health and modifiable by an intervention. a one-size-fits-all response will not suffice because the effectiveness of interventions can vary across groups. , [ ] [ ] [ ] [ ] 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, [ ] [ ] [ ] 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 months before death. 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), 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. 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. , risks and buffers for loneliness should be a focal target in interventions to protect wellbeing. the longer-term consequences of covid- 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- and social and physical distancing? the optimal structure of a mentally healthy life for individuals in the wake of covid- 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. [ ] [ ] [ ] the social and personal resources (eg, seeing family and getting sufficient sleep) available to individuals can be important resiliencerelated factors for mitigating mental health difficulties under particularly stressful circumstances. we need what is the effect of covid- on risk of anxiety, depression, and other outcomes, such as self-harm and suicide? improve monitoring and reporting of the rates of anxiety, depression, self-harm, suicide, and other mental health issues; determine the efficacy of mechanistically based digital and non-digital interventions and evaluate optimal model(s) of implementation determine the mechanisms (eg, entrapment and loneliness) that explain the rates of anxiety, depression, self-harm, and suicide; understand the role of psychological factors in buffering the effect of social context on mental health issues; ascertain the longer-term consequences on wellbeing of covid- for the young and older generations (and vulnerable groups) what is the optimal structure for a mentally healthy life in the wake of covid- and social or physical distancing? determine what psychological support is available to help front-line medical and health-care staff and their families; understand the psychological (eg, coping), physiological (eg, sleep and nutrition), and structural (eg, work rotas and daily routines) factors that protect or adversely affect mental health 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 imple mentation of preventive interventions in the future. , during the covid- 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. given the association between sleep disturbance and mental health, and the effect of sleep disturbance on the risk of suicide, 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, , exercise, social activities, training in assertiveness and conflict resolution, and group interventions that provide support through peers. 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. 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. population-level factors, such as the effect of social distancing measures (more recently being redescribed as physical distancing) and other necessary public health measures, affect mental health within a syndemics approach (table ) . 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 longer-term strategic programmes what are the mental health consequences of the covid- lockdown and social isolation for vulnerable groups, and how can these be mitigated under pandemic conditions? determine the best ways of signposting and delivering mental health services for vulnerable groups, including online clinics and community support; identify and evaluate outreach methods to support those at risk of abuse within the home; ascertain which evidence-based interventions can be rapidly repurposed at scale for the covid- pandemic, and identify intervention gaps requiring bespoke remotely delivered interventions to boost wellbeing and reduce mental health issues; swiftly provide interventions to promote mental wellbeing in front-line health-care workers exposed to stress and trauma that can be delivered now and at scale on the basis of the intervention gaps identified, design bespoke approaches for population-level interventions targeted at the prevention and treatment of mental health symptoms (eg, anxiety) and at boosting coping and resilience (eg, exercise); develop innovative novel universal interventions on new mechanistically based targets from experimental and social sciences (eg, for loneliness consider befriending) that can help mental health; assess the effectiveness of arts-based and life-skills based interventions and other generative activities including exercise outdoors what is the effect of repeated media consumption about covid- in traditional and social media on mental health, and how can wellbeing be promoted? understand the role of repeated media consumption in amplifying distress and anxiety, and optimal patterns of consumption for wellbeing; develop strategies to prevent over-exposure to anxiety-provoking media, including how to encourage diverse populations to stay informed by authoritative sources they trust; mitigate and manage the effect of viewing distressing footage inform evidence-based media policy around pandemic reporting (eg, clearly identify authoritative sources, encourage companies to correct disinformation, and policies on traumatic footage); mitigate individuals' risk of misinformation (eg, improve health literacy and critical thinking skills and minimise sharing of misinformation); understand and harness positive uses of traditional media, online gaming, and social media platforms what are the best methods for promoting successful adherence to behavioural advice about covid- while enabling mental wellbeing and minimising distress? understand how health messaging can optimise behaviour change, and reduce unintended mental health issues; track perceptions of and responses to public health messages to allow iterative improvements, informed by mental health science synthesise evidence base of lessons learned for future pandemics, tailored to specific groups as required; motivate and enable people to prepare psychologically and plan practically for possible future scenarios; understand the facilitators and barriers for activities that promote good mental health, such as exercise; promote people's care and concern for others, fostering collective solidarity and altruism covid- =coronavirus disease . interacting health effects and societal forces that fuel them combine to form syndemics, or complex knots of health determinants. research priorities around covid- require us to embrace complexity by deploying multidimensional perspectives. what are the mental health consequences of the covid- 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 con sequences of the covid- 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. , , 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 ). 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 ). , , therefore, loss of access to mental health support, alongside loss of positive activities, might increase vulnerability during covid- lockdown. increased feelings of anxiety and depression in response to the outbreak have been highlighted already. 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. the pandemic intersects with rising mental health issues in childhood and adolescence. , , 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, , as is considering vulnerabilities, such as special educational needs and developmental disorders, and finding therapeutic levers. 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. there is an acute need to identify, in consultation with people with lived experience, remotely delivered interventions that support those at risk of abuse. , 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 populationlevel 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 although the whole population is affected by the coronavirus disease 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. 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. 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. , 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 % of britons without internet access. 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). , tailoring of such universal interventions will need to be informed by exper imental and social science (eg, for loneliness, befriending, and physical activity). , the effectiveness of arts-based interventions also needs to be assessed as do other generative activities that boost positive coping and resilience throughout society, from community-based activities, to life-skills classes, to exercising outdoors. the effectiveness of all interventions requires rigorous evaluation and implementation to avoid recommending a plethora of apps with no evidence base. 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- 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. social media can be a source of rapidly disseminated misinformation, amplifying perceptions of risk. repeated media exposure to information about an infectious disease particularly can exacerbate stress responses, amplify worry, and impair functioning. anxiety and uncertainty can drive additional media consumption and further distress, creating a cycle that can be difficult to break. 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. the immediate research priority is to better understand the role of repeated media consumption around covid- 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 overexposure to media, and mitigate and help manage the effect of viewing images with traumatic content. longer-term research priorities should inform evidencebased 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. 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 pandemicnecessitates ensuring people know what to do, are motivated to do it, and have the skills and opportunity to enact the changed behaviours. , messaging is key for good knowledge, 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. 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 can be heavily influenced by anxiety, and symptoms of obsessive compulsive disorder can be associated with fear of contagion and rigid handwashing. increasing people's confidence and clarity in what they need to do fosters position paper adherence to health behaviours, and can help people to manage psychological distress. immediate research on covid- 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 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 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. almost nothing is known with certainty about the effect of sars-cov- infection on the human nervous system. sars-cov- is a zoonotic virus and a review from suggested that about half of zoonotic virus epidemics have been caused by neurotropic viruses that invade the cns. the closely related coronaviruses responsible for the severe acute respiratory syndrome epidemic in and the so-called middle east respiratory syndrome in are biologically neurotropic and clinically neurotoxic, causing mental health and neurological disorders. [ ] [ ] [ ] sars-cov- has a similar receptor-binding domain structure to sars-cov and probably shares its neurotropism and neurotoxicity (panel ). neurological symptoms of covid- infection are common, diverse, and often severe. in a retrospective study of patients in wuhan, china % had cns symptoms or disorders and the subgroup of patients with severe respiratory disease had significantly increased frequency of cns problems ( %). the problems reported include dizziness, head ache, 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. 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- infection of the brain could be a contributor to the core medical syndrome of respiratory distress and failure in patients with covid- . 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 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- crisis in the nhs and other health-care systems. in the longer term, it is possible that sars-cov- will have persistent direct neurotoxic effects and immunemediated neurotoxic effects on the brain. the spanish flu epidemic of - was linked to a spike in incidence of post-encephalitic parkinsonism. currently, it is not known if sars-cov- infection could cause mental health or neurodegenerative disorders immediately or years after the acute respiratory phase of covid- has passed, but action is needed now to build the research capacity to test these potentially important biological causes of covid- -related mental illness. immediate actions include the development of a neuropsychological database of covid- cases to bring together standardised, longitudinally repeated data at scale both from the clinic for those needing hospital facilities for sars-cov- -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- 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- might enter the brain. there are two conceivable pathways: neuronal or vascular. the neuronal pathway, used by other coronaviruses, , is to invade a specialist sensory receptor in peripheral tissue, travel by the axonal transport systems to the brainstem, and propagate between neurons by transsynaptic mechanisms. it is not known whether sars-cov- can follow the same path to infect the human brain or whether it invades nerve cells by hijacking angiotensin converting enzyme (ace ), - despite neurons expressing low amounts of the protein, as described in a preprint and two other published studies. , alternatively, sars-cov- might invade the brain from the blood, if circulating particles of the virus were transported across the blood-brain barrier by binding to ace receptors expressed by endothelial cells, or if infected leucocytes could carry the virus with them as they migrate into the tissues as part of the immune response to infection. better understanding of how the intense systemic immune response to sars-cov- infection affects mental health and neurological symptoms, , , and of the mechanisms of immune clearance of sars-cov- , is also needed. , 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- 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. [ ] [ ] [ ] candidate biomarkers need to be evaluated to measure the effects of sars-cov- 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 tesla mri technique has sufficient spatial resolution to measure functional connectivity between subcortical structures that constitute networks for respiratory control and distress. 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- , interventions need to be developed to interrupt or prevent the adverse biological effects of sars-cov- on brain function and mental health. potential drug targets include putative mechanisms for neuronal invasion, interneuronal propagation, and immune clearance of sars-cov- . biological and clinical validation of these or other targets would enable experimental medicine studies or early clinical trials of repurposed drugs. for example, the ace inhibitors already licensed for treatment of hypertension, and a licensed drug for reflux oesophagitis, camostat mesylate, that blocks the serine protease tmprss (which operates with ace 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, 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. many of the immediate priorities are for surveillance of general and specific populations for effects of sars-cov- 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. for general hospital settings, which provides near realtime information from health records (eg, to provide feedback on neurological consequences of severe covid- ). 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- . second, surveillance through recruitment platforms and existing cohorts has the benefit of embedding research on covid- into studies where participants' mental or cognitive health has previously been ascertained. existing cohorts or data platforms that can be rapidly deployed for covid- 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 webbased mental health survey of individuals, and the ongoing neuroimaging studies of individuals with some repeat imaging, provide an ideal opportunity to image the effect of sars-cov- infection on the brain and the brainstem via a before-and-after imaging comparison. third, novel population-based studies on mental health and covid- 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 . 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- 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- 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- 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 ). multidisciplinary mental health science research must be central to the international response to the covid- 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. research on human participants should maintain high standards of ethical practice, including seeking research ethics committee approval. committees now have fast-track procedures to expedite study start up. ethical considerations for doing coronavirus disease (covid- )-related research have been published. , 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, should also be considered. 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. 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, including rapid peer review of study protocols before data collection, will help to minimise waste and ensure conclusions are empirically sound. the challenge of the covid- 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". 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. 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 ). 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- pandemic across the whole population and in specific vulnerable groups, and on brain function, cognition, and mental health for patients with covid- 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- . 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 worldleading 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. 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. 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 selfharm; 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 . 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 the stakeholder survey was funded by mq: transforming mental health. activity costs for this work, 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ethical considerations in responding to the covid- pandemic what's next for registered reports? toward a global health approach: lessons from the hiv and ebola epidemics 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. key: cord- -dc oyftd authors: koehlmoos, tracey pérez; anwar, shahela; cravioto, alejandro title: global health: chronic diseases and other emergent issues in global health date: - - journal: infectious disease clinics of north america doi: . /j.idc. . . sha: doc_id: cord_uid: dc oyftd infectious diseases have had a decisive and rapid impact on shaping and changing health policy. noncommunicable diseases, while not garnering as much interest or importance over the past years, have been affecting public health around the world in a steady and critical way, becoming the leading cause of death in developed and developing countries. this article discusses emergent issues in global health related to noncommunicable diseases and conditions, with focus on defining the unique epidemiologic features and relevant programmatic, health systems, and policy responses concerning noncommunicable chronic diseases, mental health, accidents and injuries, urbanization, climate change, and disaster preparedness. prevailing concerns and expected future trends, as seen clearly in the reemergence of tuberculosis and malaria as key health problems that have become global and individual country health priorities. infectious diseases have always had a decisive and rapid impact on shaping and changing health policy with global pandemics such as severe acute respiratory syndrome (sars) and h n , emerging without warning and challenging approved priorities within days if not hours. however, it is important not to lose sight of other areas of health and to maintain a close and watchful eye on trends and developments in those diseases that do not generate the immediate impact that some infectious diseases have been able to do. noncommunicable diseases fall into this group; they may not have garnered as much interest or importance over the past or years, but in fact have been affecting public health around the world in a very steady and critical way, becoming the leading cause of death in both developed and developing countries. this article discusses emergent issues in global health related to noncommunicable diseases and conditions. trying to offer an in-depth discussion on such a wide range of issues in just one article is clearly not possible, and therefore focus and emphasis is given to defining the unique epidemiologic features and relevant programmatic, health systems, and policy responses concerning noncommunicable chronic diseases (ncds), mental health, accidents and injuries, urbanization, climate change, and disaster preparedness. in the shadow of global efforts to achieve the millennium development goals (mdgs), by far the largest killer on the planet has continued to advance in low-income and middle-income countries. ncds cause % of all global deaths but receive just . % of international development assistance for health. approximately % of deaths caused by ncds occur in developing countries, generally in a younger population than those in high-income countries. , over the next years, the world health organization (who) predicts that ncd deaths will increase by % globally with the greatest increases in the african ( %) and the eastern mediterranean ( %) regions. in terms of the highest absolute number of deaths, the western pacific and south-east asia are projected to lead the field. noncommunicable diseases are a group of illnesses and include those conditions that have been identified as the leading causes of death around the world: heart disease, stroke, cancer, chronic respiratory diseases, and diabetes. these diseases are characterized by their long latency period often influenced by exposure to risk factors for extended periods over a patient's lifetime. the situation becomes more acute with the addition of the word "chronic," indicating that these diseases are mostly incurable and the duration of treatment may cover decades of a person's life. cardiovascular disease (mainly heart disease and stroke) is the biggest killer worldwide, contributing to % of global deaths each year. the importance of such a high figure can be seen in the countries that make up latin america and the caribbean, where cardiovascular disease alone accounts for % of the total mortality burden while aids, tuberculosis, malaria, and all other infectious diseases combined are responsible for only % of that burden. globally, chronic disease deaths have been predicted to increase by % between and . although research on multimorbidity has been based primarily on high-income countries, experts estimate that around % of the population living with chronic disease may actually be living with multiple chronic conditions. sometimes erroneously referred to as "lifestyle diseases," ncds are affected by a variety of risk factors that are often outside the control of the individual. there is very little that can be done about some risk factors, such as age and genetic inheritance, and increasing evidence suggests that what happens before a person is born and during early childhood plays a key role in the onset of adult chronic disease, demonstrated by the proven association between low birth weight and increased rates of high blood pressure, heart disease, stroke, and diabetes. however, the most common chronic diseases share some of the same highly preventable or avoidable risk factors including physical inactivity, tobacco use, and obesity, leading researchers to study mortality for ncds by risk factor. the who estimates that each year approximately . million people die from tobacco use, . million from being overweight or obese, . million as a result of raised cholesterol levels, and . million as a result of raised blood pressure. raised cholesterol and raised blood pressure (hypertension) are particularly dangerous risk factors because they can exist in an individual for a long time without presenting any obvious symptoms. in its seminal book preventing chronic disease: a vital investment, the who presents what it defines as effective and feasible interventions to reduce the threat of ncds, with low-income and middle-income countries being specifically targeted. the who seeks ideally to reduce the burden of ncd mortality by % per year through the implementation of the who framework convention on tobacco control (fctc), which was the first global treaty negotiated by the who in . as of it had been signed by nations, although stages of ratification vary. the fctc contains guidelines for implementing demand-reducing policies toward tobacco including health policies aimed at protecting the public with respect to commercial and other vested interests of the tobacco industry, protection from exposure to tobacco smoke, packaging and labeling of tobacco products; and limits or bans on tobacco advertising, promotion, and sponsorship. tax increases for tobacco control are considered to be clinically effective and very cost-effective relative to other health interventions, while the implementation of smoking bans in public areas appears to reduce the risk of heart attacks significantly, particularly among younger individuals and nonsmokers, according to a study published in the journal of the american college of cardiology (september , issue). researchers reported that smoking bans can reduce the number of heart attacks by as much as % per year. , policy level programs are also being discussed for reducing salt and sugared beverages , in the diet, consumer products, and food outlets. the who report also encourages screening for which there are clear public health benefits and cost benefit, and in situations in which the ability to treat the condition (such as raised blood pressure and cervical cancer) exists. however, at present the quality and quantity of research investigating the actual benefits of different intervention programs to prevent noncommunicable diseases in developing countries is sparse and exists primarily as case studies. , low-income and middle-income countries have developed their health provision and policies according to a primary care or alma ata model, focused on meeting the needs of pregnant women and children younger than years, and developing services for a variety of high-impact communicable diseases such as human immunodeficiency virus (hiv)/aids, tuberculosis, and malaria. the health systems in these countries are unprepared to deal with risk-factor education and behavior modification for the prevention, diagnosis, and treatment of ncds, or the long-term management of these conditions. despite growing interest among the population and health system leadership, one high-ranking health official pointed out that currently, donor countries are operating a policy ban on funding ncds, thereby starving low-income governments of the financial and technical assistance needed to turn around the ncd epidemic. this policy has to change, with overseas development assistance aligned to the priorities of recipient countries. this situation continues to be an issue for developing countries despite numerous calls for action in the area of ncds and funding. , , [ ] [ ] [ ] furthermore, there is a clear inequity inherent in noncommunicable diseases, as the poor and less educated are more likely to be exposed to several preventable risk factors including tobacco use, high-fat and energy-dense food consumption, physical inactivity, and obesity. there is no denying that noncommunicable diseases are linked to economic loss, and the who highlighted this in , predicting that national income loss due to heart disease, stroke, and diabetes for china, india, and the united kingdom are expected to be $ billion, $ billion, and $ billion, respectively, with part of the losses being the result of reduced economic productivity. the global burden of disease (gbd) project began in and since then chronic diseases have exceeded the burden of infectious diseases. despite this, the international community has yet to display a sense of urgency toward reducing ncds or supporting ncd-focused interventions in developing countries, even though they are threatening development and economic progress. perhaps the situation will change in the near future with the participation of united nations (un) member states in a highlevel summit on noncommunicable diseases scheduled to take place in new york in september . although nothing can be guaranteed, similar un summits have provided the catalyst for change, as seen following the summit on hiv/aids in that resulted in significant funding and political commitment to a coordinated action plan. since , the who has defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." however, mental illness and related conditions have never received the same importance or consideration as other areas of health despite their enormous burden on the population. this fact is exemplified by the routine exclusion of mental health services from primary health care (phc) and the absence of any mental health-related objectives in the mdgs. , mental illnesses, including behavioral, neurologic, and substance use disorders, affect a significant number of the world's population. in , the who estimated that globally million people suffered from depression, million from schizophrenia, and million from substance use disorders, with around , people committing suicide every year. in the same year, unipolar depressive disorders were ranked as fourth in terms of burden of disease, well on the way to prove the prediction of the gbd analysis that estimated mental illness, specifically unipolar major depression, would become the second leading cause of burden of disease by , second only to ischemic heart disease. studies in phc settings in turkey, the united arab emirates, france, vietnam, and zimbabwe revealed that the prevalence of mental illness ranges between % and % among adults, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] with depression being the most common ranging from % to %, followed by generalized anxiety disorders ( %- %) and dependency on addictive substances ( %- %). [ ] [ ] [ ] children are not immune to mental health problems, with those aged between and years exhibiting a prevalence of mental illness of between % and %, , the most common diagnoses being anxiety disorders, major depression, behavioral disorders, and attention-deficit/hyperactivity disorder. , mental illness has an effect on other family members, which is seen clearly in a study looking at growth rates of children with mothers suffering from mental illness. the study showed that % of these children suffered from stunted growth, which could have been averted if interventions to treat the maternal depression had been performed. , individuals suffering from severe form of depression are at increased risk of attempting suicide, as are women who experience abuse. meanwhile, the prevalence of mental health problems among elderly people is %, the majority of whom suffer from depression. , cost-effective treatment for most mental illnesses exists and, if correctly applied, most patients become functioning members of society, leading normal lives even in low-resource areas, and suicide risk is reduced. of interest, poverty indicators are related to mental disorders - with low education level being the most influential determinant. extrapolating these data, it is feasible to suggest that developing countries with low education levels will tend to have a higher proportion of the population suffering from mental health problems. despite this, however, most low-income and middle-income countries spend less than % of their health expenditure on mental health. explicit mental health policy, legislation, mental health treatment facilities, and community care are all lacking. injuries as a global health issue include many types that are routinely reported to and published by the who, such as poisoning, falls, drowning, burns, and intentional injuries including interpersonal violence such as elderly, partner, or child abuse, and collective violence such as war. however, two of the most important injuries that contribute to high global death rates are road traffic accidents and occupational injuries. in , an estimated % of all global deaths were the result of an injury. injuries not only affect morbidity and mortality rates but also have a tremendous effect on the individual, the family, and the community. box presents the scope of injuries and their importance as a national health issue. it is predicted that by , road traffic injuries will be the fifth leading cause of death. already, approximately . million people die due to road traffic accidents each year, and an additional to million are injured or disabled. despite being home to fewer than % of the world's motor vehicles, low-income and middleincome countries have % of the mortality burden for road traffic accidents. one injuries prove to be the largest killer of children between and years of age, accounting for % of all classifiable deaths. this means that children per day die of injuries or children per hour. the leading cause of injury-related deaths among children is drowning ( . %) followed by road traffic accidents ( . %), animal bites ( . %), and suicide ( . %). it is estimated that injuries permanently disable around , children per year in bangladesh. nonfatal injuries occur in approximately million children per year or per minute (institute of child and mother health, ). when injury-related deaths are broken down by type and by age group, children aged - and - years are most likely to die from drowning with a mortality rate of per , and per , child deaths, respectively. in the - year age group, road traffic accidents account for per , child deaths, and in the - year age group, suicide accounts for per , child deaths. of the most important reasons for this apparent discrepancy is the high number of vulnerable road users in developing countries. vulnerable road users include pedestrians, cyclists, and both the rider and passenger of motorcycles and scooters. vulnerable road users account for % of deaths, and in low-income countries pedestrians account for nearly half of all road accident-related deaths. there are proven interventions that can lead to a reduction in the amount of road traffic deaths and injuries. such measures include controlling or reducing the speed of traffic with speed bumps or low-speed zones in urban areas, establishing and enforcing blood alcohol concentration limits, enforcing the use of helmets for both riders and passengers on motorcycles, and enforcing the use of seat belts, infant seats, and child booster seats. the wearing of seatbelts in automobiles can reduce front-seat passenger deaths by % to % and rear-seat passenger deaths by % to %; however, only % of countries require the wearing of seat belts by all passengers. the problem is that because of the high numbers of both people and different types of vehicles in developing countries and the lack of resources to police traffic effectively, traffic laws are not easily enforced, despite evidence showing the benefit of specific interventions in the reduction of traffic-related morbidity and mortality. occupational injuries are a significant problem in global public health, contributing to between , and , deaths worldwide each year. with great shifts in industrialization from the developed to the developing countries, it is logical that the highest number of occupational injuries is shifting in the same way toward the developing world. however, it is very likely that published figures are underestimated, with numbers probably being % below the actual figure for the united states and as much as % for some locations such as rural africa. , although several factors come into play when analyzing the causes of underreporting in developing countries, one of the main reasons is the lack of adequate data. determining the actual prevalence of occupational injury is critical for several reasons: ( ) to provide accurate data to health providers, policy makers, nongovernmental organizations (ngos), and the public; ( ) to provide baseline data against which to measure interventions; ( ) to aid priority setting and targeting for policy change and interventions; and ( ) to estimate societal costs of rising occupational injuries. tools to capture occupational injury have been designed and widely circulated by the un's specialized agency, the international labour organization. however, field testing of the tools has been limited to small-scale surveys in diverse settings such as vietnam, ghana, and bangladesh, - and larger, nationally representative studies are needed. in many developing countries, there is a lack of policy for or enforcement of safe working environments, which naturally means that wood cutting, mining, agriculture, construction, and manufacturing are more hazardous than in developed countries. the developed world has accepted that poor working conditions and practices are unacceptable and has legislated against them, leading to a reduction in occupational injuries over the past century. however, it seems that globally the same care has not been forthcoming, and developing countries have taken on the burden of heavy industry and poor working conditions that generate increases in occupational injuries. this trend is perfectly exemplified by the phrase "export of hazard" to describe when an outdated and dangerous technology is relocated from a high-income country to a developing country, despite the knowledge that the risk of injury with this technology is high. cost of production plays a key role in maintaining poor working conditions, and many industries in developing countries manage cost control through the use of manual labor, which is cheaper than the infrastructure and equipment needed to upgrade a process that produces the same amount of product at a much safer level. manual labor is particularly exploited in the construction industry in developing countries, which have a disproportionate number of deaths from workers falling and injuries from falling objects. working conditions at all levels of commerce are also full of risk factors to health, from the lack of ergonomically designed offices to avoid back injuries and repetitive stress disorders, to building materials used in construction, which may offer a long-term risk of health problems. the latter is of particular concern in many low-income and middle-income countries, with construction still making use of asbestos despite the documented links to lung cancer. , urbanization urbanization is a major public health challenge for the twenty-first century, with significant changes in our living standards, lifestyles, social behavior, and health. previously more of a phenomenon in developed countries; it is now taking hold and being seen at a greater level in developing countries. the united nations population fund (unfpa) predicts that over the next to decades, almost all the world's population growth will be in urban areas in developing countries. who figures for the period to already show an alarming increase in urban population growth, with developing countries' urban areas growing at an average of . million people per week or around , people every day. while urban settings offer many opportunities including access to better health care, they can affect existing health risks and introduce new health hazards. the living and working conditions of those living in rapidly expanding and poorly planned urban areas often experience risks to health in some of the most basic areas such as unsafe drinking water, unsanitary conditions, poor housing, overcrowding, hazardous locations, and exposure to extremes of temperature. these increases in health risks are particularly critical for those most vulnerable: children younger than years, infants, and the elderly. , the rapid growth of urban settlements is often due to poor economic performance of the area in question and lack of urban planning and regulation, which has resulted in an increase in the number and size of informal settlements or slums in many cities. it is estimated that in the developing regions, more than % of urban residents live in slums. the urban health situation the current pattern of urban growth is expected to have a multiplier effect on many dimensions of illness and disease. child mortality is already high in the urban areas of developing regions. in nairobi, where % of the city's population lives in slums, child mortality in these slums is . times greater than in other areas of the city. evidence from various surveys and studies points to a heavier burden of diseases such as diarrheal diseases, acute respiratory diseases, malnutrition among children, hiv/aids, tuberculosis, malaria, diabetes, and obesity on the urban poor. , , migration, increased mobility, changes in the ecology of urban environment, high population density, poor housing, and poor provision of basic services all act as pathways for emerging and reemerging communicable diseases. , the consequence of these changes is evident in the spread of multidrug-resistant strains of tuberculosis that is placing the urban poor of india, indonesia, myanmar, and nepal at a higher global health risk. vector-borne diseases such as dengue and malaria are also increasing in many urban areas, due to migration, climate change, stagnant water, insufficient drainage, flooding, and improper disposal of solid waste. , unhealthy lifestyles characterized by unhealthy nutrition, reduced physical activity, and tobacco consumption due to rapid and unplanned urbanization are associated with common modifiable risk factors for chronic diseases such as hypertension, diabetes mellitus, and obesity. urban environments tend to discourage physical activity and promote unhealthy food consumption. overcrowding, heavy use of motorized transport, poor air quality, and lack of safe public spaces are some urban factors that restrict participation in physical activities. in the larger populated cities of asia obesity is becoming a significant problem, and the rapid transition of diets in developing countries is typified by the coexistence of child malnutrition and maternal obesity in the same household. one of the main factors identified as causing an increase in diabetes worldwide is the change in traditional diets caused by urbanization. urbanization is exacerbating the health risks in terms of traffic accidents, injuries on the street or in the home, and mental health problems. the changes in climate and rising sea levels work toward increasing urbanization, with million people living in the low-elevation coastal zones being at heightened risk of flooding, which will lead to migration to higher elevations and larger cities. adopting preventive measures to control communicable diseases, upgrading the infrastructure of existing health facilities, increasing human resource capacity, and taking appropriate measures for providing equitable health services to all, especially the most vulnerable groups, are vital for improving urban health. recently, the who identified key areas of action for improving urban health: . promote urban planning for healthy behaviors and safety . improve urban living conditions, including access to adequate shelter and sanitation for all . involve communities in local decision making . ensure cities are accessible and age-friendly . make urban areas resilient to emergencies and disasters. however, these actions will only be effective if there is strong collaboration between health authorities, urban planning agencies, environmental agencies, energy providers, and the transportation systems. climate change is an emerging threat to global public health. it is now widely accepted that climate change is occurring as a result of emission of greenhouse gases, especially from fossil-fuel combustion. climate change is predicted to affect many natural systems and habitats, for example, increasing the frequency and intensity of heat waves, increasing the number of floods and droughts, altering the geographic range and seasonality of certain infectious diseases, and disturbing food-producing ecosystems, which in turn will affect human health both directly and indirectly. direct health effects include changes in mortality and morbidity, and changes in respiratory diseases from heat waves. in terms of indirect health effects, these are much more extensive and include changes in the distribution of vector-borne diseases, the nutritional and health consequences of regional changes in agricultural productivity, and the various consequences of rising sea levels, flooding, and droughts. [ ] [ ] [ ] climate change is highly inequitable, and the paradox is that those at greatest risk are the poorest populations in developing countries who have contributed least to koehlmoos et al greenhouse gas emissions. however, the rapid economic development and concurrent pollution means that developing countries are now vulnerable to adverse health effects from climate change and, simultaneously, are becoming an increasing contributor to the problem. , although the effects of climate change affect all levels and ages of any single population, the elderly and those with preexisting medical conditions are seen as being the most vulnerable. conversely, major diseases that are most sensitive to climate change such as diarrhea, malaria, and infection associated with malnutrition are most serious in children living in poverty, making them highly vulnerable to the resulting disease burden. heat waves are expected to increase the occurrence of heat-related illnesses such as heat exhaustion and heat stroke, and aggravate existing conditions related to circulatory, respiratory, and nervous system problems, especially among the elderly. , in , a major heat wave affected most of western europe and caused additional deaths in england and wales. another consequence of high temperatures is that they raise the levels of ozone and other air pollutants, which in turn aggravate respiratory diseases such as asthma. meanwhile, health impacts due to natural disasters, such as floods, droughts, and storms, range from immediate effects that include physical injury, mortality and morbidity, and communicable diseases, to possible long-term effects such as malnutrition and mental health disorders. from to , flooding was the most frequent natural disaster ( %), killing almost , people and affecting over . billion people worldwide. droughts increase the risk of food shortages and malnutrition, and increase the risk of diseases spread by contaminated food and water, because viral load increases in water sources when levels drop dramatically. rising temperatures, irregular rainfall patterns, and increasing humidity affect the transmission of many vector-borne and water-borne diseases such as malaria, dengue, cholera, and other diarrheal diseases. vector-borne diseases currently kill approximately . million people each year while . million die from diarrheal diseases. studies suggest that by , climate change may put million people in africa at risk of malaria, , and by the s the global population at risk of dengue is likely to increase to billion. , recent published data provides evidence of an association between the el niñ o and la niñ a phenomena, which are major determinants of global weather patterns, and some infectious diseases. evidence shows that there is an association between el niñ o and malaria epidemics in parts of south asia and south america, and with cholera in coastal areas of bangladesh. , studies of malaria have already revealed the health impacts of climate variability associated with el niñ o, including large epidemics on the indian subcontinent, colombia, venezuela, and uganda. one of the most immediate problems related to changes in climate and climate patterns is that on food production and availability. each year approximately . million people, mostly children from developing countries, die from malnutrition and related diseases. it is projected that climate change will decrease agricultural production in many tropical developing regions, thus putting tens of millions more people at risk of food insecurity and adverse health consequences of malnutrition. disasters in certain areas of high food production will also affect global prices, thereby affecting not only those people living in the affected region but others around the world who depend on food produced from that region. the who gbd study in indicated that the climatic changes that have occurred since the mid- s would be having an effect by the year , with , deaths ( . % deaths globally each year) and . million lost disability-adjusted life years (dalys) per year ( . % global dalys lost per year). the estimated effects are predicted to be most severe in those regions that already have the greatest disease burden of climate-sensitive health outcomes, such as malnutrition, diarrhea, and malaria. , , many of the projected impacts on health are avoidable, and public health policy makers need to act to reduce or negate the impact caused by climate change through a combination of short-term public health interventions that aim to adapt measures in health-related sectors, such as agriculture and water management, and long-term strategy. the most effective responses are likely to be strengthening of the key functions of environmental management, surveillance and response to protect health from natural disasters and changes in infectious disease patterns, and strengthening of the existing public health systems. , however, countries need to assess their main health vulnerabilities and prioritize adoptive action accordingly, keeping in mind the costs involved. natural disasters know no boundaries, and any nation or population can be subject to a catastrophic disaster at any time. however, some nations and populations are more at risk of disasters than others due to geographic location, poverty, and several sociopolitical factors. this issue of disaster risk reduction (drr) rose to global prominence in the aftermath of the tsunami in the indian ocean in december . following a disaster, some populations suffer more acutely than others. it is worth considering the complex issues of how societies organize themselves in terms of risk and actual prevention and care, for access to clean water and sanitation, and how they communicate and initiate behavioral change among the displaced or fragile populations. at the forefront of most discussions when planning post-disaster management and action is the priority placed on certain elements of disaster relief, such as the building of embankments, the distance to clean water, or the time from incident to response. recent examples of varying responses and outcomes were seen following the two cyclones in south asia. there was a relative success in bangladesh in terms of lives saved and response coordination after cyclone sidr in november , compared with the devastating loss of more than , lives after cyclone nargis in myanmar in may , not to mention the loss of draft animals and dykes, and the flooding of fields during planting season. bangladesh reverted to its welldeveloped program for drr that includes national-level coordination, whereas in myanmar there was no national platform for disaster preparedness, and delays occurred in the coordination of international response to the disaster. in addition to the immediate and obvious impact of natural disasters, conditions often worsen in poorly coordinated settings, as evidenced in when vibrio cholerae emerged in post-flood pakistan, and for the first time since the s in post-earthquake haiti. in general, there are factors that can turn a natural disaster into a complex disaster regardless of the severity or magnitude of the initiating event such as a hurricane, earthquake, or tsunami. according to the un department of humanitarian affairs, the factors are: poverty, ungoverned population growth, rapid urbanization and migration, transitional cultural practices, environmental degradation, lack of awareness and information, and war and civil strife. poverty is by far the single greatest factor that contributes to the vulnerability of a population to complex disasters. in addition to lacking financial resources to prepare for or recover from a disaster, impoverished people are also more likely to have low levels of education and low amounts of political influence to properly deal with a disaster situation. in addition to increases in birth rates, rapid population growth can be the consequence of urbanization or migration. population growth without limits produces a population that is more likely to settle in areas that are unsuitable or at risk for natural disasters, meaning that more people are at risk of disease and, most importantly, are more likely to undergo civil strife while competing for scarce resources. as mentioned previously, rapid urbanization and migration lead to impoverishment. former rural populations make themselves more vulnerable to disaster by settling in less developed or high-risk city environs, often leading to homelessness or living in urban slums that have circumvented any planning controls or regulations. such populations therefore are made more vulnerable to floods, landslides, and the destruction of their dwelling during a hurricane or earthquake. transition of cultural, economic, or government practices such as the increase in migration from rural to urban areas, economic advancements, families moving away from traditional support networks and to unfamiliar surroundings, and the shift from an agrarian to an industrialized society leave certain societies vulnerable to natural disasters. environmental degradation can play a role by either causing or exacerbating a disaster. for example, deforestation can work in two ways: firstly enabling runoff or secondly, making landscapes vulnerable to storms, due to lack of natural wind breaks. everyone is aware of the natural conditions that provoke droughts, but through the construction of dams, unchecked urbanization, implementation of poor cropping patterns, and the depletion of water supplies, man-made droughts are becoming more widespread. it is clearly of upmost importance to ensure that populations are informed about what to do to prepare in advance of a natural disaster such as a hurricane, and also are able to fend for themselves following the event. a lack of awareness and the dissemination of accurate information is a major factor that can turn one disaster into a multiple or complex disaster involving, for example, subsequent outbreaks of cholera, malnutrition, and physical injury. war and civil strife are extreme events that can both produce disasters or be caused by disasters, normally as a result of the preceding factors. the phrase for disasters that specifically strike war-torn populations is complex humanitarian emergencies. global efforts to address and capture the importance of disaster risk and poverty have been hampered by a lack of data, especially from asia, latin america, and the caribbean. empirical evidence linking disaster risk to poverty tends to come from microstudies within one community, making it impossible to generate generalized findings across regions or entire countries. prompted by the devastation that followed the tsunami on december, , there was widespread acceptance that an early-warning system should be installed and other actions taken to prevent loss of life where possible. the world conference on disaster reduction was held in japan in january , and resulted in the creation of the hyogo framework for action - (hfa), which was endorsed by un member states and urges all countries to make major efforts to reduce their disaster risk by . the hfa outlines the need to increase awareness and understanding about drr, the importance of knowing the real and potential risks, and taking action against them. specific recommendations included the need to create or enhance early-warning systems, build drr into education, and reduce risk factors such as deforestation, unstable housing, and the location of communities in risk-prone areas. although different areas of the planet experience different risks, the one common factor is that drr "concerns everyone, from villagers to heads of state, from bankers and lawyers to farmers and foresters, from meteorologists to media chiefs." to support common needs within regions, associations and networks have been established to support drr, such as the south asian saarc disaster management center and the caribbean disaster emergency response agency. types of activities that can feature in a national or regional drr program can include: establishing early-warning systems; using local knowledge of events; building an awareness of risk and risk preparedness through community activities; building flood-resistant buildings and safe homes; developing contingency plans; helping communities and individuals develop alternative sources of income; and establishing insurance or microfinance programs to help transfer the risk of loss and provide additional resources to the community. in addition to chronic diseases, mental health problems, injuries, and complex disasters, communities should consider increasing risks from more than new or reemerging diseases that have appeared since the s: liver disease due to the hepatitis c virus; lyme disease; food-borne illnesses caused by escherichia coli o :h ; cyclospora, a water-borne disease caused by cryptosporidium; hantavirus pulmonary syndrome; and human disease caused by the avian h n influenza virus. the increasing number of new and reemerging diseases is not the only risk factor that should be added to the planning processes for developing a drr program. drug resistance in treating many diseases and illnesses is a major concern, as witnessed in malaria and tuberculosis, and with a highly mobile world population, global pandemics such as sars, h n , and h n , for which treatments either are not available or levels of suitable drug are clearly not sufficient for a worldwide epidemic, are proving to be very challenging. this clear inability to predict and maintain sufficient levels of treatment for potential threats makes health risk reduction extremely difficult, and in developing countries where resources are already stretched to cope with existing health issues, creating effective programs will require intervention from social partners, global support organizations, and aid from the developed world. an ever quickening pace of globalization means that public health-related problems in one area of the world will have an impact on those living in another area and therefore, it is in everyone's interest to ensure that all countries, irrespective of their economic development and available resources, are sufficiently supported to maintain and review strategies that will effectively reduce morbidity and mortality rates in all spheres of public health. preventing chronic diseases: a vital investment a race against time: the challenge of cardiovascular disease in developing economies non-communicable diseases: time to pay attention to the silent killer. press release missing in action: international aid agencies in poor countries to fight chronic disease when people live with multiple chronic diseases: a collaborative approach to an emerging global challenge the developmental origins of chronic adult disease world health organization framework convention on tobacco control [who fctc]. guidelines for implementation global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis public smoking bans are good for the heart chronic diseases and calls to action ounces of prevention-the public policy case for taxes on sugared beverages the neglected epidemic of chronic disease chronic diseases: the case for urgent global action grand challenges in chronic noncommunicable diseases social distribution of cardiovascular disease risk factors: change among men in england - the global burden of disease: a comprehensive assessment of mortality and disability from disease, injuries, and risk factors in and projected to preamble to the constitution of the world health organization as adopted by the international health conference no health without mental health the millennium development goals report world health organization projections of global 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evolution of complex disasters united nations-international strategy for disaster reduction united nations-international strategy for disaster reduction [un-isdr] living with risk. a global review of disaster reduction initiatives disaster risk management and climate change adaptation in south asia. dhaka: portfolion new and reemerging diseases: the importance of biomedical research key: cord- -naj nl x authors: ibáñez-vizoso, jesús e; alberdi-páramo, Íñigo; díaz-marsá, marina title: perspectivas internacionales en salud mental ante la pandemia por el nuevo coronavirus sars-cov- date: - - journal: rev psiquiatr salud ment doi: . /j.rpsm. . . sha: doc_id: cord_uid: naj nl x nan j o u r n a l p r e -p r o o f en lo que llevamos de siglo xxi han tenido lugar diferentes epidemias causadas por enfermedades infecciosas como el sars (síndrome respiratorio agudo grave) o el mers (síndrome respiratorio de oriente medio). algunos estudios han descrito un importante impacto psicológico de estas epidemias sobre la población general, los pacientes y los sanitarios, proponiendo diferentes medidas para garantizar la salud mental y evitar la progresión de psicopatología en estas circunstancias , . la reciente aparición y rápida propagación en wuhan (china) del nuevo coronavirus sars-cov- supuso la toma de medidas sin precedentes como el cierre de wuhan y la cuarentena de millones de habitantes en provincias y localidades adicionales . el enorme impacto psicosocial de estas acciones, junto con los antecedentes descritos, impulsaron la rápida aparición en china de diversos servicios de asistencia psicológica basados en procedimientos de intervención en crisis . posteriormente se han promovido diferentes abordajes en salud mental en países como corea del sur, japón o españa a medida que el virus se ha propagado internacionalmente , . a finales de se reportaron en wuhan los primeros casos de una neumonía de causa desconocida. pronto se identificó el coronavirus sars-cov- como agente causal de la enfermedad covid- . generalmente cursa con fiebre, tos y disnea, presentando una tasa de mortalidad de aproximadamente el % , . el de enero de la oms declaró covid- como epidemia y pheic (public health emergency of international concern). el de marzo se calificó como pandemia tras su rápida propagación internacional. los efectos sobre la salud mental de la nueva epidemia son en su mayoría desconocidos . en la epidemia de sars de , los pacientes afectados en un hospital de toronto experimentaron miedo, soledad, ira, efectos psicológicos de los síntomas de la infección y preocupación por la cuarentena y por producir contagios. en el personal sanitario destacó el miedo al contagio. la estigmatización afectó tanto a pacientes como a profesionales . entre el personal de urgencias en taiwán, el . % presentó sintomatología significativa de síndrome de estrés postraumático . en la epidemia de mers de de corea del sur se vio que entre los pacientes aislados predominaban síntomas de ansiedad e ira, especialmente en pacientes con antecedentes psiquiátricos . estas epidemias, causadas por otros coronavirus, pueden ofrecer pistas sobre los posibles efectos sobre la salud mental de covid- en la población general, entre los pacientes y entre el personal sanitario. entre la población general, en un estudio realizado en china, más de la mitad de los encuestados refirieron un impacto psicológico moderado-grave, mientras que un . % y un . % refirieron respectivamente síntomas depresivos y de ansiedad de intensidad moderada-grave . se ha señalado que entre los sujetos que padecen una enfermedad mental el impacto podría ser todavía mayor , . en cuanto a los pacientes diagnosticados de covid- , se ha sugerido que pueden experimentar miedo y malestar por las consecuencias potencialmente fatales de la infección y la situación de aislamiento. por otra parte, los síntomas de la infección y los efectos adversos del tratamiento, como el insomnio producido por corticoides, podrían empeorar la ansiedad y el malestar psíquico . el personal sanitario se enfrenta a retos como el desbordamiento asistencial, el riesgo de infección, exposición al desconsuelo de las familias y dilemas éticos y morales , . un estudio en china encontró entre ellos una alta prevalencia de síntomas de depresión, ansiedad e insomnio ( , %, , % y , %, respectivamente). las mujeres, enfermería, y los trabajadores más expuestos reportaron más síntomas . en conjunto, estos datos despiertan preocupación sobre el bienestar psicológico del personal sanitario implicado. la pandemia por covid- también ha requerido la cuarentena de múltiples sujetos expuestos a la infección, con efectos inciertos sobre su salud mental. en una revisión reciente sobre el efecto de la cuarentena en algunas epidemias de este siglo (sars, mers, gripe a/h n y ébola) se describen una mayor prevalencia de malestar psicológico, síntomas afectivos (ánimo bajo o irritabilidad) y de estrés postraumático, algunos de los cuales podrían ser duraderos. el miedo al contagio, la falta de información, las pérdidas financieras y el estigma son algunos de los factores estresores que asociaron a la cuarentena, por lo que se proponen medidas dirigidas a mejorar la comunicación o a facilitar los medios materiales necesarios . se han establecido algunos principios generales para la intervención con pacientes y personal sanitario como: a) soporte psicológico por equipos multidisciplinares, con screening clínico para ansiedad, depresión y riesgo suicida; los pacientes con comorbilidad psiquiátrica deben beneficiarse de un seguimiento adecuado; b) información precisa a pacientes y personal sanitario; mantenerse actualizado y corregir la desinformación; c) atención a síntomas como el insomnio como marcador clínico precoz; d) esfuerzos para evitar el aislamiento interpersonal; e) anticiparse e informar sobre las reacciones de estrés, enseñando a reconocer los signos de malestar y discutiendo estrategias para reducirlo. las respuestas de la mayoría de los pacientes y del personal sanitario son adaptativas ante un estrés de estas características , , . j o u r n a l p r e -p r o o f en definitiva, dado el elevado impacto psicosocial de la pandemia por el coronavirus sars-cov- es necesario continuar con la implementación y el desarrollo de servicios de salud mental en la respuesta sanitaria ante covid- . la descripción de las estrategias adoptadas internacionalmente puede orientar de cara a su aplicación en diferentes contextos sanitarios. mental health status of people isolated due to middle east respiratory syndrome wen soon s. psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china the mental health of medical workers in wuhan, china dealing with the novel coronavirus 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novel coronavirus outbreak caring for patient's mental well-being during coronavirus and other emerging infectious diseases: a guide for clinicians psychological crisis interventions in sichuan province during the novel coronavirus outbreak a novel approach of consultation on novel coronavirus (covid- )-related psychological and mental problems: structured letter therapy mental health care measures in response to the novel coronavirus outbreak in korea public responses to the novel coronavirus ( -ncov) in japan: mental health consequences and target populations cuide su salud mental durante la cuarentena por coronavirus best practices in videoconferencing-based telemental health key: cord- -t g zc authors: swendsen, joel title: covid- and mental health: how one pandemic can reveal another date: - - journal: j behav cogn ther doi: . /j.jbct. . . sha: doc_id: cord_uid: t g zc the covid- pandemic disproportionately affected individuals with mental disorders, and revealed fundamental flaws in how vulnerable persons are treated in the context of such crises. much of this difficulty may be attributed to ignorance of the prevalence, severity and economic burden associated with these conditions, as well as to enduring inequalities in how physical illness is treated in comparison to mental illness. as mental disorders are now the single greatest cause of disability, we have reached the point where the tremendous personal and societal costs associated with these conditions can no longer be ignored. dramatic changes are needed to replace the slow, incremental efforts that most often characterize public health policy. such changes can no longer wait for the national or international-level solutions that were once hoped, but they may be just as effective through the use of new technologies, grass-roots organization, and initiatives on a local scale. in a very short period of time, the covid- pandemic dramatically altered how individuals function, work and interact with others. never before has society relied as much on new technologies and the internet to assure productivity and communication, and many of these changes are certain to last far beyond the current public health crisis. the pandemic has also taught us two very difficult but important lessons about mental health. the first is that individuals with mental disorders disproportionately bear the burden of such crises. in addition to being vulnerable due to their condition, the added travel restrictions, social distancing and home confinement -all necessary measures to control the pandemic -are fully opposite to what is commonly used in cognitive and behavioral therapies to effectively treat these disorders. a second lesson is that the majority of therapeutic progress needs to be made by patients when they are not with their clinician. it is at those moments, often when at home and alone, that patients need to remember to take their medications, to avoid risk factors and to perform adap-tive behaviors or exercises. many individuals with mental disorders were unprepared for such autonomy and self-help during confinement, and society was unprepared to reach out to them. for these reasons, the viral pandemic that is covid- has also highlighted the existence of a chronic and major mental health crisis. yet surprisingly, most people are still unaware of its magnitude or severity. the impact of any disease or disorder can be measured by disability adjusted life years (dalys), which represent the number of years lost due to ill-health, disability, or early death. it has been acknowledged for years that mental disorders are among the leading causes of disability worldwide when considering dalys (whiteford et al., ) . this enormous societal burden is explained by both the high prevalence of these conditions as well as by the severe impairment they induce. numerous large-scale epidemiologic investigations have demonstrated that major mental disorders such as schizophrenia, anxiety disorders, mood disorders, or substance dependence will affect large sec-editorial tions of the general population at some point over their life span (compton et al., ; kessler et al., ; kessler et al., ; merikangas et al., ; regier et al., ) . the epidemiologic studies with the highest rates (notably including the national comorbidity survey, or ncs) were also those that took steps to overcome biases leading to the under-reporting of disorder prevalence. in particular, this series of studies understood the limitations of door-to-door diagnostic assessment and the biases associated with structured diagnostic interviews. concerning the former, many people with mental disorders may initially refuse participation when solicited by survey agents simply because they do not have the energy or desire to participate. after their initial refusal, the ncs asked a subset of these individuals to again participate while explaining why their initial refusal made them particularly important to include in the study and additional incentives were offered. a portion of those who initially refused to participate the first time finally agreed to participate, allowing the ncs to estimate the degree to which individuals who initially refuse participation may be more likely to suffer from a mental disorder and to adjust their estimates accordingly. the second bias these investigations overcame concerned the fact that structured diagnostic interviews for mental disorders typically last between to hours. interviews are shorter ( hours) if the individual does not endorse key ''gate'' questions for each disorder and therefore does not need to be administered follow-up questions. for example, if the individual responded ''no'' to the question ''have you ever in your life had at least one drink containing alcohol?'', then there is no need to ask further questions concerning drinking quantity, frequency or eventual symptoms of alcohol use disorder. the problem is that after about two hours of the interview, most participants start to understand that the more they say ''yes'' to such questions, the more questions are asked. so, they tend to start saying ''no'' in order to finish the interview more quickly. the ncs overcame this issue by asking all gate questions for each disorder at the very beginning of the interview, well before the participant learned the rule that positive responses lead to more questions. once they had responded positively to those gate questions, all pertinent follow-up questions were eventually asked. using both strategies for overcoming response biases and under-reporting, the lifetime rates of mental disorders are now estimated at just under % of the population. with one in every two individuals meeting diagnostic criteria for a mental disorder at some point, these results reveal the staggering magnitude of the mental health crisis. it also means that all of our families are affected in one way or another. it is important to note, however, that the general population is not experiencing more mental disorders than before: we are just becoming more accurate at estimating the full scope of this chronic and often ignored public health crisis. any form of illness also infers economic burden. the most recent estimates indicate that the european union spent . % of its total gdp on health care (all diseases combined), but that almost half of these costs were dedicated specifically to the treatment of mental disorders (oecd/eu, ). mental health expenditures in the united states are more difficult to quantify due to the complexity of its health care services, but conservative estimates for direct costs alone approximate one trillion dollars a year (trautmann et al., ) . it can be assumed that other areas of the world are also heavily burdened financially by these common forms of illness, despite considerable differences in investment in treatment or prevention efforts. editors of scientific journals such as jbct are beginning to see increasing numbers of manuscripts addressing the mental health consequences of the covid- pandemic. but the sad truth is that although the pandemic disproportionately affected persons with mental disorders, we have not yet fully realized what has happened. the crisis was always there, hidden by a lack of knowledge by politicians, public policy-makers, and indeed the general public, of what mental disorders are and what we are facing as a society. we are still far away from the point of treating mental disorders with the same degree of attention, financial investment and prevention strategies as is accorded to serious physical diseases. as of august th, , covid- had caused , deaths worldwide (world health organization, a) . this is precisely the same number of people who commit suicide every year (world health organization, b). the difference is that covid- will likely have an end, either through a vaccine or through eventual mass immunity. the mental health crisis may very well continue, with few dramatic improvements. it will not make the national news every evening. it will not be discussed on a daily basis. in brief, it will probably continue to be treated differently than any physical health threat of the same magnitude. if this makes you angry--and it should--there is no point waiting patiently for solutions to be put into place by someone else. if you are reading this editorial, it is probably because you are a mental health researcher or clinician, just like the entire jbct editorial board. it can start very simply with us, from the bottom up. ask ourselves simple questions, such as how we can expand our skills to reach out to those who are isolated? how can we continue to ensure human contact and clinical intervention under the worst-case lockdown scenarios? could it involve mobile technologies, social media, neighborhood organizations, simple phone calls? how do we analyze a vulnerable person's social support and material resources? how can we encourage our professional microcosms (the given hospital, clinic or university where we work) to coordinate broader initiatives in this direction? the covid- pandemic left the world in a state of uncertainty and indeed anxiety. but it also shed light on essential problems affective human kind as a whole, reminding us of our responsibilities and of the opportunities that can exist for lasting change. the author declares that he has no competing interest. prevalence, correlates, disability, and comorbidity of dsm-iv drug abuse and dependence in the united states: results from the national epidemiologic survey on alcohol and related conditions lifetime co-occurrence of dsm-iii-r alcohol abuse and dependence with other psychiatric disorders in the national comorbidity survey lifetime and -month prevalence of dsm-iii-r psychiatric disorders in the united states. results from the national comorbidity survey lifetime prevalence of mental disorders in u.s. adolescents: results from the national comorbidity survey replication -adolescent supplement (ncs-a) health at a glance: europe : state of health in the european union comorbidity of mental disorders with alcohol and other drug abuse. results from the epidemiologic catchment area (eca) study the economic costs of mental disorders global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study key: cord- -ls vud authors: khan, farah; eskander, noha; limbana, therese; salman, zainab; siddiqui, parveez a; hussaini, syed title: refugee and migrant children’s mental healthcare: serving the voiceless, invisible, and the vulnerable global citizens date: - - journal: cureus doi: . /cureus. sha: doc_id: cord_uid: ls vud millions of children are on the run worldwide, with many unaccompanied children and adolescents undertaking risky journeys to flee war, adverse circumstances, and political persecution. the grueling journey and multiple stressors faced by the refugee children, both accompanied and unaccompanied during the pre-migration, migration, and in the country of destination, increase their risk for psychiatric disorders and other medical conditions. unaccompanied refugee migrant children have higher prevalence of mental health disorders than accompanied refugee peers. long after reaching the host country, the refugee, migrant, and asylum-seeking juveniles continue to face adversities in the form of acculturation. in assessing medical fitness and healthcare mediations for refugees and migrant children, special consideration should be given to certain areas such as their distinct history, whether they are with their family or separated or unaccompanied, and whether they have been peddled or have been left behind. an alarming number of children travel with family or alone without proper care to flee organized violence, war, and persecution in their native country. some cross their national borders to become refugees and seek asylum in other countries, a legal process recognized by the united nations. without a family or an adult, these children are often at risk of being exploited and abused. most of the refugee children live in nearby countries close to their own native place of origin that happen to be low-or middle-income countries [ ]. in , in italy about % of children arriving by sea were separated and unaccompanied [ ] . in , the high-income countries resettled , refugees [ ] . in , juveniles under years of age incorporated about half of the refugee population [ ] . in , uganda recorded , child refugees, the largest number of unaccompanied and separated child refugees with the overwhelming majority aged under and a couple thousand aged under . from - , turkey has been hosting . million refugees, the largest refugee population [ ] . in , the most common country of origin among child asylum seekers happens to be syrian arab republic. in , germany registered % of all child asylum applications lodged in europe ( , children), while the highest number of first-time applicants with regard to its population was greece [ ] . the grueling journey faced by the refugee children, both accompanied and unaccompanied during the pre-migration, migration, and in the country of destination, is associated with multiple stressors resulting in elevated risks for psychiatric disorders and other medical conditions [ ] . the clinicians should be aware that exposure to war, a long arduous journey with minimum or no care, and ongoing stressors that refugee kids have experienced are associated with physical, developmental, and mental health problems. this migration is in itself dangerous, and apart from mental and other health costs to it there is also an increased risk of disabilities, and vulnerabilities to acute and chronic ailments. this article discusses some of the commonly seen mental health conditions and other medical conditions in refugee and migrant children from the reviewed articles. it also provides an insight into the refugee mental health struggles during the coronavirus (covid- ) pandemic and the migrant detention facilities. studies were selected and reviewed after applying the inclusion/exclusion criteria on pubmed. the following were the inclusion criteria: ( ) age years and younger, ( ) both female and male, ( ) articles in english, and ( ) studies published within the last one year. exclusion criteria were age above years and non-english articles. the articles selected from pubmed were broken down as seen in table . after applying inclusion/exclusion criteria and using regular keywords, the total number of articles selected after review and refined search were as they fit the selection criteria. the articles removed were not included for lack of relevant data. the flowchart seen in figure shows the starting keywords used, and the number of articles obtained on pubmed for literature search with the applied filters. finally, the total number of used articles is displayed alongside those which were not selected. barriers, economic opportunities, lack of understanding of the healthcare system, knowledge about available resources, issues pertaining to accessing health and other services, trust factor, financial problems, transportation issues, and the larger policy and political context of local authorities [ , ] . primary care physicians, pediatricians, and mental health providers can build trust through culturally competent and trauma-informed care, assess for healthcare needs, provide vaccination update and preventative care, and screen for mental health, communicable diseases, disabilities, and other medical health conditions thereby attending to the holistic needs of the vulnerable child and adolescent refugees. refugee children are less likely to avail pertinent health and social care than non-refugee children peers [ ] . most host countries offer some kind of health screening for refugees, both child and adult, upon entering the country of destination [ ] . in assessing medical fitness and healthcare mediations for refugees and migrant children, special consideration should be given to certain areas such as their distinct history, whether they have migrated along with their family or have been separated from family, are unaccompanied, whether they have been peddled, or have been left behind [ ] . children's right to medical care is guaranteed by all the world leaders and member states of the who european region and is compiled in the convention on the rights of the child (crc), a convention guaranteeing the highest attainable standard of healthcare and treatment of illness and rehabilitation of the refugee, migrant, and asylum-seeking children similar to the children native to the host country [ ] . the most vulnerable children include the asylum seekers and the undocumented or unregistered migrants. asylum seekers have usually been tested with war and/or political oppression in their native country and live in uncertainty and temporary circumstances regarding their future. the undocumented children often live in dangerous environments with little or no availability of basic societal rights, in abuse, poverty, brutality, and social boycott, and among threats of deportation [ ] . migrants face a myriad of issues during various aspects of their journey between countries. during the pre-migration phase of this process, there is a lack of access to health/dental care, scarcity of food, and exposure to diseases. during the journey, lack of access to health/dental care and food scarcity continue to be problems. additionally, human trafficking, violence, and injuries during the trip are also present. finally, in the country of destination, difficulty in finding resources presents itself as the largest barrier. these resources include health/dental care, education, therapy, and other basic amenities. this process repeats itself and becomes a cycle if migrants are deported back to their country of origin and seek to migrate once again [ ] . refugees and migrants arriving in the host country, many of which have different cultures and languages from their native country, go through a course of learning and acclimatization to the new civilization. this stressful process of acculturation compounds the migration strain thereby amplifying the psychological distress. children and adolescents, who are enrolled in school, generally learn the new host country language faster and conform to the new culture faster than parents, who may be secluded giving rise to new challenging family issues. family tensions can cause disharmony, separation, and even assault, with associated adverse effects on a child's mental health [ ] . some of the needs of the refugees and migrants include access to mental health services; the youths have a need for civil activities and community acceptance while the parental urgency is to feel culturally protected. competency in a local language of the host country, and support from local community, school, and local authorities make their transitions easier and decrease the acculturation stress. figure shows some of the mental and other health challenges of the refugee and migrant children. communicable diseases: cramped and overpopulated settlement and lack of cleanliness and sanitation in facilities housing refugee and migrant children put them at increased risk for diarrhea and skin infections [ ] . the third-world countries show a higher prevalence of tuberculosis, malaria, intestinal parasites, and hepatitis b and c, than the developed nations. these chronic infections are present in increased prevalence in refugee and migrant juveniles [ , ] . a study reports of unaccompanied refugee and migrant children who were arriving in germany with multidrug-resistant bacteria colonization at higher rates, and other records of a surge of measles, which is vaccine-preventable, have also been seen in asylum-seeking juveniles [ , ] . clinicians should have a low threshold to screen for sexually transmitted infections (stis) in adolescent refugees as they have the highest rate of curable stis worldwide [ ] . some of the commonly seen non-communicable diseases include obesity and psychological problems in migrant children [ ] . obesity could be due to stress or change in dietary habits. vitamin d deficiency is often caused by lack of exposure to sunshine in winter [ , ] . other conditions like malnutrition and multivitamin deficiencies are most likely to be prevalent too due to lack of access to food and health care in the migration journey. as per unhcr data, about , of refugee children in were unaccompanied minors [ ] . segregation from parents can be harmful to a child's health and prosperity, mostly mental health, as parents lay the foundation for the societal and environmental base for children [ ] . unaccompanied refugee minors have a higher prevalence of psychiatric disorders than accompanied refugee peers [ ] . when accompanied by families, and after having experienced the migration trauma, children are often "hidden from sight" with no regard to their own personal wishes. mental health must be seen as a complex primary healthcare need and should be served in a holistic and family-oriented manner whenever possible. research studies have shown that freshly arrived migrant and refugee juveniles are at a high risk of psychosocial and mental issues due to exposure to organized crime and migration stress [ ] . these are most commonly internalizing disorders -anxiety, depression, and post-traumatic stress disorder (ptsd) [ , ] . a study of asylum seekers with serious mental health problems, in the netherlands, found that parental symptoms of ptsd were associated to infants' troubled attachment and that parental apathy was related to parental ptsd [ ] . a cohort study found that caregivers' ordeal history and postmigration adversities were correlated with greater ptsd, rigid parenting, and an increase in child conduct problems [ ] . expressive symptoms, however, were found to be equal to that in children of the host country [ ] . longitudinal studies have shown that the high rate of internalizing symptoms tended to wear off slowly over a period of time, with expressions of ptsd fading away in about seven years after arrival to the host country [ ] . some frequently reported emotional and behavioral mental health problems among bhutanese refugee youth include fighting, loneliness, depression, and being scared. other symptoms of oppositional defiant disorder, intermittent explosive disorder, conduct disorder, generalized anxiety disorder, major depressive disorder, and disruptive mood dysregulation disorder were also seen among them [ ] . migrant and refugee juveniles frequently have to compromise more when parents are suffering from psychiatric disorders after dreadful experiences and migration strain. parents with mental health challenges battle to give their children a feeling of support and stability [ ] . migration stress with socioeconomic deprivation takes a toll on the parents and increases the risk for child abuse [ ] . early and adequate cognitive, mental, and emotional support for parents suffering from behavioral disorders is thus a vital support for children. refugees may hesitate to seek mental health help due to a culturally based stigma around mental health issues [ ] . family separation and parental death drives adolescents to take on parental roles for younger siblings. recognition of these roles will enable physicians to provide suitable emotional and social support. risk factors in the host country, such as financial hardships, parental separation, and aggression/bullying, were analyzed as vital determinants of mental health at follow-up [ ] . in recent years, cognitive behavioral psychotherapy, eye movement desensitization and reprocessing (emdr), and narrative exposure therapy for migrant and refugee children who have experienced war and displacement have been established for the evaluation and treatment of ptsd and depression [ ] . strengths of refugee children include personal resilience, parental support, close-knit family structure, and lasting association with their religious and cultural identity from the country of origin [ ] . the staggering majority, %, of the global refugee population is accepted in developing regions with limited access to quality mental health even before the pandemic [ ]. now, they are overwhelmed with mental health crisis, as warned by the unhcr. while many refugees and internally displaced people are exceptionally resilient, their abilities to cope are now being stretched to the limit. the loss of daily wages and livelihoods is taking a toll on their mental health and causing psychosocial hardships. social distancing measures and limited mobility are compounding emotional distress with reports of self-harm increasing among the refugees. the covid- precautions and reduced staffing levels during this pandemic are also impacting the availability of aid and mental health support as refugees are often unable to travel, and many face-to-face activities have been cancelled. the unhcr is stepping up efforts to ensure the continuity of care by providing mental health services remotely through multi-lingual telephone hotlines and over the internet through online sessions. in addition, they are ensuring that people who need medication can continue treatment during lockdown [ ] . the teaching recovery techniques approach is used to decrease children's discomfort and post-traumatic symptoms and to improve peer and kinfolk relations [ ] . this psychosocial intervention is meant for juveniles who have experienced dreadful circumstances. children are assembled in organized groups focused at augmenting emotional management, survival competency, and conflict resolution skills. these techniques also help the children to express themselves. there is also a parent component session to educate about intervention and on skills to reinforce care of their children. ladnaan intervention is a culturally adapted parenting guidance program combined with local civic orientation for somali-born parents living in sweden. a trained community educator of somali origin facilitates the program. parents report higher success and satisfaction after completing the course and convincing improvement in behavioral problems in their children. in this -week session, parents are educated on local community information, receive lectures and take part in workshops, and exchange views on the parent-child liaison, attachment, child growth, and development of interpersonal skills [ ] . mind-spring is a mental health disorder prohibition plan in belgium, denmark, and the netherlands. it provides psycho-education, and psychosocial and parenting skills for refugee and asylum-seeking parents in a culturally conscious manner in their own native language [ ] . it deals with topics on mental health such as stress, ordeal, depression, personality, acculturation, and mental health fitness. the program promotes exchanging thoughts on experiences and provides parents with information about mental health expertise to recognize signs of suffering and mental ailment in themselves. it also educates the parents about obtaining help if and when needed. parents also obtain the required skills and support in the parenting process and how to ploy collateral parenting issues. studies have shown that educational institutions play a vital role in conserving and promoting the health and well-being of refugee and migrant children. successful school-based mental health prevention requires experts trained in cultural proficiency, who can interpret the mental health requirements and risks of refugee and migrant children, and who can conform the learning program to the needs of the individual child and family [ , ] . hearing all voices was a pilot project undertaken by child to child in london aimed at promoting social inclusion, commitment in education, and local community involvement among vulnerable youth, with a prime focus on refugee, migrant, and asylum-seeking youth [ ] . the pharos school prevention program conducts classroom-based program in the netherlands with the aim of developing social involvement among migrant children with local host community children and adults while simultaneously attending to individualized requirements of each child [ ] . health assessments are performed for refugee and migrant children in a school setting in malmo city, sweden. here, the school nurse meets the juveniles and their caregivers for a health assessment to define and address each child's healthcare requirements. an analytical interview is followed by a broad general examination of the body, including dentition, eyesight, and hearing. mental health is briefly assessed and vaccination history is analyzed. referrals are made based on the necessity of specialized services. national governments have a significant role in establishing living circumstances for refugee and migrant children as most freshly settled refugee families rely on national and local authorities' support for habitation and existential expenses. governments determine the rights of children to access health care maintenance and educational benefits in their country. policies that exemplify humanity should be planned and implemented for the refugees/migrants and asylum seekers. a detailed individualized health evaluation by a healthcare professional on arrival to the host country should determine the healthcare needs and screen for communicable diseases; disability should be assessed and vaccinations should be updated. this response will help detect infections early on, allow timely treatment to be given, and will be most cost effective in the long run. the availability of medical translators and native cultural arbitrators is important to ensure the best healthcare outcome for refugee and migrant children. blueprints to improve welfare, and access to education and health in refugee and migrant children should have a comprehensive framework that targets risk factors on individual, family, and community levels. culturally sensitive, parent and other caregiver support curriculum and interventions in the school and local community centers should be promoted. transferring children between multiple locations should be minimized as it disrupts the peer networks and educational flow; this also holds good for unaccompanied children with substitute caregivers. in order to build good relations with substitute caregivers, unaccompanied children need consistent long-term, definitive housing with the same guardians. the most vital physical, social, and psychological support for children are their parents; therefore, family reunions should be expedited [ ] . the united states of america has built the largest immigration detention system in the world. in , a staggering , migrant children including infants, toddlers, kids, and teens were held in custody in facilities across usa. these facilities lack enough clinicians or specialized care for the detained children [ ] . immigration detention has adverse and detrimental consequences for the well-being of those detained, but studies have found that it is most inimical to children [ ] . the negative impacts of detention on mental health are more brutal for children than for adults; therefore, detention should not be weaponized for deportation of migrant children. if this is inevitable, then the facilities harboring children should have childfriendly areas, and avenues for healthcare and education should be provided. children on the move also suffer brutality, injustice, and misconduct from law enforcement officials -local police, border guards, and detention officers. such events cause children to quickly learn to mistrust authorities. these adverse psychological effects may last years after release from detention [ ] . children are global citizens and their rights move with them; therefore, their healthcare needs should not be defined by geographic borders. mounting evidence suggests welcoming and supportive policies for refugee, migrant, and asylum-seeking children can prevent psychological distress and mental health disorders in these vulnerable children. all-inclusive policies that aim at protecting the rights of every child should be enforced globally. children should not be held in detention centers indefinitely in subhuman conditions away from their parents/primary caregivers. reuniting children with their families should be prioritized and expedited. it is imperative to enforce preventative mental health policies and refrain from practices that abuse human rights. healthcare providers should consider volunteering in refugee and migrant camps, and also in local community free clinics that are accessed by refugee and migrant children. this will ensure adequate staffing in detention facilities specially during the pandemic where the invisible, voiceless, and vulnerable refugee and migrant children along with the adult refugees and migrants can get timely medical attention and treatment for their healthcare needs. research is needed on improving resilience building and for appraising the impact of precise interventions that could improve outcomes. more longitudinal studies are needed to assess interventions that increase better mental health mediterranean situation health of refugee and migrant children: technical guidance . who regional office for global trends -forced displacement latest statistics and graphics on refugee and migrant children health considerations for immigrant and refugee children migrant children in europe: entitlements to health care. models of child health appraised barriers to access to health care for newly resettled sub-saharan refugees in australia structural and socio-cultural barriers to accessing mental healthcare among syrian refugees and asylum seekers in switzerland rights of accompanied children in an irregular situation a systematic review of risk and protective factors associated with family related violence in refugee families assessing the burden of key infectious diseases affecting migrant populations in the eu/eea infectious diseases of specific relevance to newly-arrived migrants in the eu/eea multidrug-resistant bacteria in unaccompanied refugee minors arriving in frankfurt am main measles among migrants in the european union and the european economic area toward global prevention of stis): the need for sti vaccines the health of migrant children in switzerland serum levels of -hydroxyvitamin d in mothers of swedish and of somali origin who have children with and without autism high prevalence of somali population in children presenting with vitamin d deficiency in the uk. arch dis child risk of mental health and nutritional problems for left-behind children of international labor migrants incidence of psychiatric disorders among accompanied and unaccompanied asylum-seeking children in denmark: a nation-wide register-based cohort study mental health problems of syrian refugee children: the role of parental factors mental health in syrian refugee children resettling in the united states: war trauma, migration, and the role of parental stress the effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: a cohort study prevalence of serious mental disorder in refugees resettled in western countries: a systematic review attachment representation and sensitivity: the moderating role of posttraumatic stress disorder in a refugee sample we left one war and came to another: resource loss, acculturative stress, and caregiver-child relationships in somali refugee families exile and mental health in young refugees the transmission of trauma in refugee families: associations between intra-family trauma communication style, children's attachment security and psychosocial adjustment psychological interventions for post-traumatic stress disorder and depression in young survivors of mass violence in low-and middle-income countries: meta-analysis unhcr urges prioritization of mental health support in coronavirus response interventions for children affected by armed conflict: a systematic review of mental health and psychosocial support in low-and middle-income countries klingberg-allvin m: a support program for somali-born parents on children's behavioral problems school and community-based interventions for refugee and asylum seeking children: a systematic review hearing all voices in london us held record number of migrant children in custody in global protection and the health impact of migration interception mental health of unaccompanied asylum-seeking adolescents previously held in british detention centres key: cord- -pwe zoi authors: singh, dr shweta; roy, assistant professor.miss deblina; sinha, clinical psychology trainee miss krittika; parveen, clinical psychology trainee miss sheeba; sharma, clinical psychology trainee. ginni; joshi, clinical psychology trainee. gunjan title: impact of covid- and lockdown on mental health of children and adolescents: a narrative review with recommendations. date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: pwe zoi background: covid- pandemic and lockdown has brought about a sense of fear and anxiety around the globe. this phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. the quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection. aims: this paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by covid- pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection. methodology: we conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the covid- pandemic. we selected articles and thematically organized them. we put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. we have also provided recommendations to the above. conclusion: there is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. there is a need to ameliorate children and adolescents’ access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. for this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary. this paper is aimed at reviewing articles related to mental-health aspects of children and adolescents impacted by covid- pandemic and lockdowns. there is a need to carry out longitudinal and developmental studies and plan strategies to enhance children's and adolescent's access to mental health services during and after the current crisis. for this direct and digital collaborative network of psychiatrists, psychologists, pediatricians, and community volunteers are of vital importance. background: covid- pandemic and lockdown has brought about a sense of fear and anxiety around the globe. this phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. the quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection. aims: this paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by covid- pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection. methodology: we conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the covid- pandemic. we selected articles and thematically organized them. we put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. we have also provided recommendations to the above. conclusion: there is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. there is a need to ameliorate children and adolescents' access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. for this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary. key words: covid- ; lockdown; mental health; children; adolescents there are more than . billion children in the world who constitute approximately % of the world's population. those aged between to years make up % of the world's population (unicef, ) . covid- has impacted the lives of people around the world including children and adolescents in an unprecedented manner. throughout the world, an essential modus of prevention from covid- infection has been isolation and social distancing strategies to protect from the risk of infection (shen et al., ) . on these grounds, since january, , various countries started implementing regional and national containment measures or lockdowns. in this backdrop one of the principal measures taken during lockdown has been closure of schools, educational institutes and activity areas. these inexorable circumstances which are beyond normal experience, lead to stress, anxiety and a feeling of helplessness in all. it has been indicated that compared to adults, this pandemic may continue to have increased long term adverse consequences on children and adolescents (shen et al., ) . the nature and extent of impact on this age group depend on many vulnerability factors such as the developmental age, current educational status, having special needs, pre-existing mental health condition, being economically under privileged and child/ parent being quarantined due to infection or fear of infection. the following sections discuss about findings of studies on mental-health aspects of children and adolescents impacted by covid- pandemic and lockdowns being implemented at national or regional levels to prevent further spread of infection. we searched the electronic data bases of medline through pubmed, cochrane library, science-direct and google scholar databases, from january, till june, . we carried out the search with the following methods like, mesh or free text terms and boolean were done by five independent reviewers. a manual search was also conducted of the references of the related articles to gather information about the relevant studies. initial pubmed search with the term with " covid- in children" showed only results. among these, only four articles were related to "psychological effects of covid in children". therefore in order to make the review more comprehensive and informative, we also included studies that reported the effect on older children and impact of covid - on their lives. this was done keeping in mind the varied terminologies used to describe the phenomenon of 'children and covid- ". after using the above strategy, our search showed results. only articles in english language peer reviewed journals were included. grey literature such as conference proceedings were not included due to possibility of insufficient information. we included case studies and review articles and advisories by the who (world health organization), apa (american psychiatric association) and nhs ( national health services) and government of india ministry of health. based on these inclusion criteria we included articles. three independent authors participated in study selection and all authors reached a consensus on the studies to be included. being a narrative review, we did not attempt computation of effect sizes or do a risk of bias assessment for included papers. the studies included were categorized under eight headings divided in various thematic sections and discussed with studies and reports found. the data is qualitatively analysed and reported in the paper. a summary of the papers included in this narrative review is presented in table . [ table is uploaded seperately] impact on young children: stress starts showing its adverse effect on a child even before he or she is born. during stress, parents particularly pregnant mothers are in a psychologically vulnerable state to experience anxiety and depression which is biologically linked to the wellbeing of the foetus (biaggi et a ; kinsella and monk, ). in young children and adolescents the pandemic and lockdown have a greater impact on emotional and social development compared to that in the grown-ups. in one of the preliminary studies during the on-going pandemic, it was found younger children ( - years old) were more likely to manifest symptoms of clinginess and the fear of family members being infected than older children ( - years old). whereas, the older children were more likely to experience inattention and were persistently inquiring regarding covid- . although, severe psychological conditions of increased irritability, inattention and clinging behaviour were revealed by all children irrespective of their age groups (viner et al., a) . based on the questionnaires completed by the parents, findings reveal that children felt uncertain, fearful and isolated during current times. it was also shown that children experienced disturbed sleep, nightmares, poor appetite, agitation, inattention and separation related anxiety (jiao et al., ) . globally, the pre-lockdown learning of children and adolescents predominantly involved one-to-one interaction with their mentors and peer groups. unfortunately, the nationwide closures of schools and colleges have negatively impacted over % of the world's student population (lee, ). the home confinement of children and adolescents is associated with uncertainty and anxiety which is attributable to disruption in their education, physical activities and opportunities for socialization (jiao et al., ) . absence of structured setting of the school for a long duration result in disruption in routine, boredom and lack of innovative ideas for engaging in various academic and extracurricular activities. some children have expressed lower levels of affect for not being able to play outdoors, not meeting friends and not engaging in the in-person school activities (lee, ; liu et al., ; zhai & du, ) . these children have become more clingy, attention seeking and more dependent on their parents due to the long term shift in their routine. it is presumed that children might resist going to school after the lockdown gets over and may face difficulty in establishing rapport with their mentors after the schools reopen. consequently, the constraint of movement imposed on them can have a long term negative effect on their overall psychological wellbeing (lee, ). a study found that older adolescents and youth are anxious regarding cancellation of examinations, exchange programs and academic events (lee, ) . current studies related to covid- demonstrate that school shut downs in isolation prevent about - % additional deaths which is quite less if compared to usage of other measures of social distancing. moreover, they suggest to the policy makers that other less disrupting social distancing strategies should be followed by schools if social distancing is recommended for a long duration (lee, ; sahu, ; viner et al., a) . however, in current circumstances, it is controversial whether complete closure of school and colleges is warranted for a prolonged period. it has been reported that panic buying in times of distress indicate an instinctual survival behaviour (arafat et al., ) . in present pandemic era there has been a rise in the hoarding behaviour among the teenagers (oosterhoff et al., a) . it is also found that among youth social distancing is viewed primarily as a social responsibility and it is followed more sincerely if motivated by prosocial reasons to prevent others from getting sick (oosterhoff et al., a) . further, due to prolonged confinement at home children's increased use of internet and social media predisposes them to use internet compulsively, access objectionable content and also increases their vulnerability for getting bullied or abused (cooper, ; unicef, b) . worst of all, during lockdown when schools, when legal and preventative services do not functioning fully, children are rarely in a position to report violence, abuse and harm if they themselves have abusive homes. there are about in every children within the age group of - years who have some or the other neurodevelopmental, behavioural or emotional difficulty (cdc, ). these children with special needs [autism, attention deficit hyperactivity disorder, cerebral palsy, learning disability, developmental delays and other behavioural and emotional difficulties] encounter challenges during the current pandemic and lockdown (cdc, ). they have intolerance for uncertainty and there is an aggravation in the symptoms due to the enforced restrictions and unfriendly environment which does not correspond with their regular routine. also, they face difficulties in following instructions, understanding the complexity of the pandemic situation and doing their own work independently. with the closure of special schools and day care centres these children lack access to resource material, peer group interactions and opportunities of learning and developing important social and behavioural skills in due time may lead to regression to the past behavior as they lose anchor in life, as a result of this their symptoms could relapse (lee, ). these conditions also trigger outburst of temper tantrums, and conflict between parents and adolescents. although prior to the pandemic, these children had been facing difficulties even while attending special schools, but in due course they had learnt to develop a schedule to adhere to for most of the time of the day (apa, ; cortese et al., ; unicef, a). to cater to these challenges, it is difficult for parents to handle the challenged children and adolescents on their own, as they lack professional expertise and they mostly relied on schools and therapists to help them out (dalton et al., ). since every disorder is different, every child has different needs to be met. the children with autism find it very difficult to adapt to the changing environment. they become agitated and exasperated when anything is rearranged or shifted from its existing setup. they might show an increase in their behavioral problems and acts of self-harm. it is a huge challenge for parents to handle autistic children due to lockdown. the suspension of speech therapy and occupational therapy sessions could have a negative impact on their skill development and the achievement of the next milestone, as it is difficult for them to learn through online sessions (unicef, a). the children with attention deficit hyperactivity disorder (adhd), struggle to make meaning of what is going around them from the cues they get from their caregivers. it is difficult for them to remain confined to a place and not to touch things, which might infect them. due to being confined to one place the chances of their hyperactivity increases along with heightened impulses and it becomes difficult for the caregivers to engage these children in meaningful activities (cortese et al., ). obsessive compulsive disorder (ocd) among the children and adolescents is estimated to be of . %- % among children and adolescents (cdc, ). children with ocd are suspected to be one of the most affected ones by this pandemic. due to obsessions and compulsions related to contamination, hoarding, and somatic preoccupation, they are expected to experience heightened distress. cleanliness is one key protective measure against the spread of covid- . according to united nations' policy guidelines to fight the infection one has to be careful about washing their hands six times a day, and whenever they touch anything (apa, ; united nations, ). the lockdown, which has made the healthy population distressed about possessing enough food and prevention related resources like masks and sanitizers, has made it worse for people with hoarding disorder (apa, ; mukherjee et al., ) social inequality has been associated with the risk of developing mental health challenges. the pandemic and lockdown world has experienced global economic turn-down which has directly worsened the pre-existing social inequality. in developing countries, with the in order to cover up the loss of education during lockdown, many schools have offered distance learning or online courses to students. however, this opportunity is not available to underprivileged children as a result of which they face a lack of stimulation and have no access to online resource material to study. a study pointed out that in underprivileged families, in comparison to boys, girls have decreased access to gadgets, this may diminish their involvement in digital platforms of education (mcquillan & neill, ). due to this gender inequality, increasing number of girls are prone to bear the consequences of school dropouts once the lockdown is lifted (cooper, ; pti, ). covid with the objective of universal prevention and mental health promotion, the international it is imperative to plan strategies to enhance children and adolescent's access to mental health services during and after the current crisis. for this direct and digital collaborative network of various stakeholders is required. recommendations for ensuring mental well-being of children and adolescents during the covid- pandemic and lockdown and the role of parents, teachers, pediatricians, community volunteers, the health system and policy makers are being discussed. in addition a brief summary of the roles is given in table . [ table is uploaded seperately] in the times of paramount stress and uncertainty, a secure family environment which the parents can provide is a strong protective factor (schofield et al., ) . there is evidence to . efforts should be made so that a consistent routine is followed by the child, with enough opportunities to play, read, rest and engage in physical activity. it is recommended that family plays board games and engages in indoor sports activities with the child to avoid longer durations of video games. parents should ensure that particularly the bedtime of a child is consistent. it is possible that before the bed time children may need some more time and attention. . focus should be on the 'good behaviour' more than 'bad behaviour' of a child. parents must tell more about options regarding what to do rather than what not to do. provide more praise and social reinforcements to children compared to material reinforcements. . it is quite possible that parents observe some amount of change in the behavior in children during the times of a pandemic. if the behavior problems are minor and not harmful for children and others, parents should consider ignoring and stop paying attention to them, this may lead to decrease in the recurrence in behavior and would also help in giving space to each other. apart from areas discussed above, certain areas which need especial focus in the phase of adolescence, are being described below: . this is an opportunity for older children to learn responsibility, accountability, involvement, and collaboration. by taking some responsibilities at home on an everyday basis, for instance maintenance of their belongings and utility items. they can learn some of the skills including cooking, managing money matters, learning first aid, organizing their room, contributing to managing chores like laundry, cleaning and cooking. . excessive internet use e.g. internet surfing related to covid- should be avoided as it results in anxiety. similarly, excessive and irresponsible use of social media or internet gaming should be cautioned against. negotiations with adolescents to limit their time and internet-based activities are recommended. more non-gadget related in door activities and games are to be encouraged. . in such conditions taking up creative pursuits like art, music, dance and others can help to manage mental health and well-being for everyone. inculcating self-driven reading by making them select books of their choice and discussing about them helps in adolescent development. . adolescence is a phase of enthusiasm and risk-taking, hence some may feel invincible and try not to follow guidelines related to distancing and personal hygiene. this has to be addressed with adolescents assertively. . it is crucial to value the peer support system of the adolescents. parents should encourage adolescents who are introverts to keep in touch with their peers and communicate with them about their feelings and common problems they face. this may also lead a way for appropriate problem-solving. . it is advised to parents to take care of their own mental health needs and try to cope with stress adaptively. in the present times when most schools and colleges are organizing online academic activities, teachers are in regular touch with students, and therefore are in a position to play a critical role in the promotion of psychological well being among youngsters. their role during covid- pandemic and lockdown are as follows: . teachers can devote some time related to educating about covid- and preventive health behavior by using the guidelines of the international organizations, according to the maturity level of the students. they can explain to the students about the need to act with responsibility during the current pandemic. they can model and enact through their behavior the preventive measures. . they can conduct creative online academic and non-academic sessions by making their classes more interactive, engaging students in the form of quizzes, puzzles, small competitions, and giving more creative home assignments to break the monotony of the online classes. standard educational material can be used. for instance, unesco has offered many online educational sources (unesco, ) they can discuss what is wellbeing and how it is important for students. they can assist in teaching simple exercises, including deep breathing, muscle relaxation, distraction, and positive self -talk. virtual workshops can be conducted in which 'life skills' related to coping in stress can be in focus by using more practical examples. . teachers can make children understand the importance of prosocial behavior and the importance of human virtues like empathy and patience among others. this can help them to understand their role in the society and understand how social distancing is not equivalent to emotional distancing. . the teachers need to interact with parents online or through phone regarding feedback about students and their mental health. because of the digital divide they can call parents, make their contact available to parents and devote a time slot when they can be available to parents to communicate. . they can serve as a doorway for identification and referral to specialty mental health providers. they have a role act as a catalyst between the parent based on their interaction with students and findings of screening tools. if they observe any problem in the child, they can talk to parents and refer children and adolescents to mental health professionals. . with the support of school authorities, teachers need to make arrangements to ensure that the reading material related academics and life skills is made available to the underprivileged children who do not have access to the internet. if possible arrangements can be made for them to use internet. during a child's formative years when their personalities are shaped, parents are in regular touch with pediatricians, as parents reach out to their local pediatricians whenever they encounter health/ behavioral complaints associated with their children. parents expect answers from them as they trust them. hence a pediatrician's role is paramount in promoting ptsd, depression, substance abuse in adolescents should also be addressed on similar lines. there is a requirement for creative solutions, often on a case-by-case basis. . psychiatrists need to carefully weigh the risks and benefits of psychotropic medications for children and adolescents e.g. anti-depressants, anxiolytics, anticonvulsants, etc., and if possible, arranging medicines for those who cannot arrange. . there is a need for mental health care workers carry out longitudinal and developmental studies on short term and long term mental health impact of the covid pandemic and lock down on children and adolescents. it has been recognized by the world that the traditional pre-covid- models and policies for children and adolescents' mental health are no longer applicable during covid era. hence, the need is felt for the transformation of policies that can take into account not only lock down duration but also times following the lockdown. the following recommendations may be useful for guiding the functioning of the health system and policy making related to mental health care of children and adolescents : . the focus of the health care system should be prevention, promotion, and treatment according to the public mental health system to meet population-mental health needs of the general population at large. no single umbrella policy would be able to take into account various mental health aspects of children and adolescents dwelling in different environments. hence the health system and policies should be based on contextual parameters that are different for each country or region depending on the degree of infection and the phase of infection they are in. . since there is a dearth of mental health care workers in most developing countries. there is a need for inclusive approaches in which health care workers e.g. pediatricians, general physicians, schools, non-governmental organizations sectors are involved. moreover, brief basic mental health care training for these arms should be planned. . separate rules for the rural, suburban, and concrete domiciles in growing countries spotting the variance among college districts, which includes city, suburban, and rural districts. the studies included in the review were collected after setting criteria to have a comprehensive view of the global vision in managing the crisis of children in the covid- pandemic. the majority of the studies included in the review were based on online selfreports (bhat et al., ; jiao et al., ; oosterhoff et al., b) . the adults and older children were the respondents of the study (lee, ; liu et al., ; viner et al., b; wang et al., (wade et al., ) . the review articles for this review have been selected during the time of global lockdown, where the issues and challenges were new and the global crisis was at peak times. in our review, we were unable to track the measures of management targeted towards the children. the strategies reported in the studies were isolated to geopolitical conditions. the recommendations provided in this review can be modified to suit the needs of the places according to their local resources and geopolitical scenarios. due to strict selection criteria and the short period of data collection and the only use of electronic databases for our research, there is a possibility of missing studies relevant to the care of children and adolescents. although the rate of covid- infection among young children and adolescents is low the children who receive training, therapy, and other treatments are at high risk of being derailed from therapy and special educations. economically underprivileged children are particularly prone to exploitation and abuse. children quarantined are at high risk for developing higher risk for mental health-related challenges. there is a need to ameliorate children and adolescent's access to mental health services by using both face to face as well as digital platforms. for this collaborative network of parents, psychiatrists, psychologists, pediatricians, community volunteers, and ngos are required. there is a need for 'tele mental health compatibility' and be accessible to the public at large. this would be crucial to prevent during and post-pandemic mental challenges in the most vulnerable and underprivileged section of the society. the focal point of the health care system and policymaking should be prevention, promotion, and interventions corresponding to the public mental health system to meet the mental health needs of the population at large by taking the regional contextual parameters into account. disclosure of prior presentation of study data: this paper has not been submitted in full or part in any conference and is not being considered for publication elsewhere. creating material for community volunteers and ngos for identifying high risk children e.g. underprivileged children, children of migrants, provide psychological first aid, coordinating with care givers and mental health care professionals. quarantined parents/children parents if child is separated to keeping contact as much as possible, being supportive and reassuring coordinating with care givers, referring to mental health care professionals foster care givers being supportive, reassuring and educating constructing and administring online questionnaires in order to detect psychological distress and other symptoms for children if they or their parents are quarantined, providing extra support to them and developing ad hoc supportive interventions. impacts of covid- on vulnerable children in temporary accommodation in the uk. the lancet public health closure of universities due to coronavirus disease (covid- ): impact on education and mental health of students and academic staff professional foster carer and committed parent: role conflict and role enrichment at the interface between work and family in long-term foster care diagnosis, treatment, and prevention of novel coronavirus infection in children: experts' consensus statement children's mental health in times of economic recession: replication and extension of the family economic stress model in finland global population of children children with autism and covid- policy brief: the impact of covid- on children school closure and management practices during coronavirus outbreaks including covid- : a rapid systematic review. the lancet child & adolescent health school closure and management practices during coronavirus outbreaks including covid- : a rapid systematic review. the lancet child & adolescent health why we need longitudinal mental health research with children and youth during (and after) the covid- pandemic detection of sars-cov- in different types of clinical specimens healthy parenting who | covid- : resources for adolescents and youth world health organization mental health care for international chinese students affected by the covid- outbreak the authors whose names are listed below certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants, participation in spakers' bureaus arrangements, consultancies, memberships, stock ownerships, or other equity interest, or expert testimony and patent licencing arangements) or non financial interests such as ( personal or professional relationships, affiliations, knowledge or beliefs)in the subject matter or materials discussed in this manuscript. all the authors confirm that, all of them has contributed in the conception of design; analysis, interpretation of data; drafting the article; critically revisiting the article for important intellectual inputs; and approval of the final version. this paper has not been submitted elsewhere or is under review at another journal or publishing venue. the authors have no affiliation with any organization, with a direct or indirect financial interest in the subject matter discussed in the manuscript. authorities to be more transparent in their negotiations and to allow candidates sufficient notice to prepare emotionally as well. students to be timely provided counselling. key: cord- - a djjm authors: benke, christoph; autenrieth, lara k.; asselmann, eva; pané-farré, christiane a. title: lockdown, quarantine measures, and social distancing: associations with depression, anxiety and distress at the beginning of the covid- pandemic among adults from germany date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: a djjm the covid- pandemic is suggested to have a negative impact on mental health. to prevent the spread of sars-cov- , governments worldwide have implemented different forms of public health measures ranging from physical distancing recommendations to stay-at-home orders, which have disrupted individuals’ everyday life tremendously. however, evidence on the associations of the covid- pandemic and public health measures with mental health are limited so far. in this study, we investigated the role of sociodemographic and covid- related factors for immediate mental health consequences in a nationwide community sample of adults from germany (n = ). specifically, we examined the effects of different forms and levels of restriction resulting from public health measures (e.g. quarantine, stay-at-home order) on anxiety and depression symptomatology, health anxiety, loneliness, the occurrence of fearful spells, psychosocial distress and life-satisfaction. we found that higher restrictions due to lockdown measures, a greater reduction of social contacts and greater perceived changes in life were associated with higher mental health impairments. importantly, a subjectively assumed but not an officially announced stay-at-home order was associated with poorer mental health. our findings underscore the importance of adequate risk communication and targeted mental health recommendations especially for vulnerable groups during these challenging times. the coronavirus disease has recently evolved into a global crisis affecting the physical and mental health of people worldwide. due to the rapid dissemination of the sars-cov- virus and its potential deleterious effects for physical health, governments worldwide have imposed different forms and levels of public health measures ranging from physical distancing recommendations to stay-at-home orders to contain an uncontrolled spreading of the sars-cov- virus. although being effective in preventing a further dissemination of the coronavirus (nussbaumer-streit et al., ) , these measures may have changed peoples" everyday life significantly and may have led to an immediate disruption of self-regulated behavior and a reduction of social connections (e.g. loss of reinforcer and social support, perceived controllability) which may lead to specific mental health problems, especially in vulnerable people (lewinsohn and atwood, ; brooks et al., ; holmes et al., ) . moreover, people are faced with the risk of a potentially life-threatening covid- infection, which may trigger feelings of uncertainty, fear, anxiety and even result into social isolation (asmundson and taylor, ; mertens et al., ) . a few previous studies from different countries worldwide investigated the role of sociodemographic and covid- related factors for mental health (gonzález-sanguino et al., ; losada-baltar et al., ; pierce et al., ; tull et al., ; wang et al., ; see luo et al., ; vindegaard and eriksen benros, for a review). their findings suggest that especially women, younger people, as well as individuals with a mental disorder, chronic somatic disease, and predisposing factors for a potentially severe course of covid- are at risk for mental health problems during these challenging times. however, studies on the effects of different forms and levels of restrictions resulting from public health measures (e.g., stay-at-home orders, being quarantined or reduction of social contacts) on mental health are scarce. studies from previous epidemics and the current covid- pandemic investigated the role of quarantine and related measures for mental health. some of these studies revealed that quarantine was associated with elevated mental health problems (wang et al. b; liu et al. ; wu et al. ; bai et al. ). however, these findings were not entirely conclusive, given that other research did not find such associations (wang et al. ; zhu et al. ; wang et al. a; zhang et al. ) . consequently, to adequately inform the public health care system and enable adequate measures to protect from or mitigate adverse mental health effects, the consequences and relevant factors influencing the psychological response to the pandemic and public health measures need to be characterized. in germany, daily infection rates rapidly increased early in march . at that time, each federal state started to implement public health measures (e.g., closure of schools and kindergartens) to prevent a further spread of covid- . although various measures were implemented all over germany, some measures (e.g. stay-home orders) and the associated degree of restriction for individuals" personal and social life differed between german federal states. the present study was conducted four weeks after all german federal states had implemented public health measures (e.g., minimum distance of . m to other persons, closure of non-essential shops, such as bookstores, warehouses; see steinmetz et al., ) . at the time of the study, the highest rate of covid- related death per day in germany was recorded since the outbreak of covid- in germany. the present study was aimed at identifying potential predictors for immediate mental health consequences to the covid- pandemic and related public health measures in germany. between th april and th may , a cross-sectional study was conducted among adults ( . % women and . % men) from all federal states of germany. participants were aged between and years (m= . years, sd= . years). the study started during the first peak of the corona crisis in germany (highest rate of covid- related deaths per day), four weeks after all german federal states had implemented public health measures. participants were recruited via convenience sampling methods (social media, personal contacts, e-mails, etc.) and completed an online survey (soscisurvey.de). all participants provided informed consent. the study was approved by the local ethics committee of the university of marburg. in addition to sociodemographic and covid- -related variables (see table for an overview), we assessed the following variables related to implemented public health measures: perceived changes in life due to public health measures: participants were asked to rate how much their everyday life had changed due to governmental measures that were taken to contain covid- spreading on a -point likert-scale (ranging from "not at all" to "very strong") and whether they perceived these changes as positive, neutral, or negative. social distancing: participants were asked to indicate how frequently they currently engage in social contacts with reference to january (prior to covid- outbreak in germany; converted scale: much less, less, unchanged) and whether they are distressed ( -point likert-scale ranging from not stressful at all to extremely stressful) by the restriction of social contacts. restrictions due to public health measures: forms of restriction measures that have been suggested to disrupt self-regulated and psychologically relevant behavior of individuals (steinmetz et al., ) were systematically recorded for each of the german federal states on a day by day basis (e.g., prohibition to meeting with others in public places, closure of kindergartens or daycare, prohibition to leave the apartment without reason) by the leibniz institute for psychology information (zpid, germany). each type of restriction was coded as not present (= ), partially (= ) or fully (= ) in place. for each public health measure, we determined the highest level of restriction (i.e., not present, partially or fully in place) within the period prior to the start of the survey. afterwards, the score of each measure was summed up to determine the overall level of personal and social restrictions resulting from public health measures in each federal state. stay-at-home-order: data provided by the zpid were also used to objectively determine which german federal state had announced a prohibition to leave the apartment without reason. perceived stay-at-home order: moreover, participants were asked to indicate whether they assumed that the government of their federal state had imposed a prohibition to leave the apartment without reason. this allowed us to delineate the effect of officially announced and subjectively perceived stay-at-home-orders on psychological outcome measures. the following psychological outcome measures were assessed: depressive symptoms were assessed with the patient health questionnaire- (phq- ; kroenke et al., ) . generalized anxiety was assessed with the -item generalized anxiety disorder scale (gad- ; spitzer et al., ; kroenke et al., ) , health anxiety with the short mental health during the covid- pandemic version of the whitely index (fink et al., ; hiller et al., ) , moreover, using the respective question of the dsm- cidi, participants were asked to indicate whether they had experienced a fearful spell during the last weeks. loneliness was assessed with the -item version of the ucla loneliness scale (russell, ) . psychosocial distress (e.g., due to financial problems or worries, distress at work, distress resulting from childcare, etc.) was assessed with the stress module of the patient health questionnaire. finally, and as in previous research (see lucas and donnellan, ) , general life satisfaction was assessed with a single item ("all things considered, how satisfied are you with your life these days?") and a -point likert-scale ranging from (completely dissatisfied) to (completely satisfied). statistical analyses were conducted with spss (spss for windows, ibm). analyses including data provided by the zpid (restrictions by public health measures and officially announced stay-at-home orders) were limited to those participants who reported their zip codes (n= ). first, linear regressions (adjusted for gender and age) were used to test associations of sociodemographic and covid- -related factors with psychological outcomes. second, all sociodemographic and covid- -related variables being significantly associated with outcomes were used as multiple predictors for outcome measures. the alpha level was set at . . in the present study, . % of the sample exceeded the cutoff score for a potential depression diagnosis (phq- ≥ ), . % exceeded the cutoff score for a potential anxiety disorder diagnosis (gad- ≥ ), . % exceeded the cutoff score for health anxiety (wi- ≥ ), . % reported to be lonely (loneliness ≥ ), . % of the sample reported mild psychosocial distress (phq stress module scores ranging between and ), while . % reported moderate to severe psychosocial distress (phq stress module ≥ ). . % of the sample reported having experienced a fearful spell during the last weeks. the mean score of life-satisfaction was . (sd = . ). associations between sociodemographic factors and psychological outcomes are presented in table . female sex, younger age, a lower educational level, being unemployed, being single, living alone, living without underage children and a current or past psychotherapeutic or psychiatric treatment were associated with higher depressive symptomatology. female sex, younger age, a lower educational level, being unemployed, living alone, as well as current or past psychotherapeutic or psychiatric treatment were associated with higher anxiety symptomatology. being unemployed or not working and current or past psychotherapeutic or psychiatric treatment was associated with higher health anxiety. younger age, lower educational level, being unemployed, living alone and current or past psychotherapeutic or psychiatric treatment were associated with higher loneliness. female sex, younger age, lower educational level, living together in a relationship, living with underage children and a current or past psychotherapeutic or psychiatric treatment were associated with higher psychosocial distress. female sex, older age, a higher educational level, being employed, cohabiting with a partner, cohabiting with children, no current or past psychotherapeutic or psychiatric treatment were associated with higher life-satisfaction. being in self-quarantine was associated with higher health anxiety and with fearful spells. however, being quarantined by a local health authority was not associated with any psychological outcome. belonging to an officially announced covid- risk group was associated with higher anxiety and depressive symptomatology, health anxiety, fearful spells, higher psychosocial distress, and lower life-satisfaction. having contact to loved ones that belong to an officially announced covid- risk group was associated with higher health anxiety and lower loneliness. having a confirmed diagnosis of covid- was associated with higher loneliness, while a confirmed diagnosis of covid- in loved ones was not associated with any outcome measure. a higher level of restriction due to public health measures was associated with higher loneliness, higher psychosocial distress, and lower life-satisfaction. a stronger reduction of social contacts, higher distress due to restrictions of social contacts, stronger perceived changes in life due to the public health measures and a more negative appraisal of these perceived changes were positively associated with higher anxiety and depressive symptomatology, fearful spells, psychosocial distress and lower life-satisfaction. there was no association (expect for social distancing related distress) of theses predictors with health anxiety. . % of the sample correctly reported that there was no officially announced stay-athome order in their federal state, while . % of the current sample correctly reported to live in a federal state in which government had announced a stay-at-home order. however, . % of the sample reported that there was an officially announced stay-at-home order in their federal state, despite the fact that there was no governmental imposed prohibition to leave the apartment without reasons. . % of the sample negated that the government has officially announced a stay-at-home order, while their federal state has officially announced a stay-at-home order. there was no association of officially announced stay-at-home orders with psychological outcome measures (see table ). however, perceived stay-at-home orders were associated with higher anxiety and depressive symptoms, fearful spells, higher psychosocial distress, higher loneliness, and lower life-satisfaction (see table ). perceived stay-at-home orders were unrelated to health anxiety. moreover, to test whether perceived stay-at-home orders interacted with officially announced stay-at-home orders in predicting scores on psychological outcome measures an interaction term was included in the regression analysis. the moderation analysis revealed that an officially announced stay-at-home order did not interact with the perceived stayat-home order in predicting mental health outcomes. that is, participants who believed that government had announced a stay-at-home order reported higher scores on psychological outcome measures whether or not government has officially announced stay-at-home orders in their federal state (officially announced x subjectively perceived stay-at-home order interaction, βs = -. -. , or = . , all ps > . ). moreover, negating a stay-at-home order despite the fact that government has announced a stay-at-home order was unrelated to our mental health outcomes (β = -. -. , or = . , all ps > . ). table summarizes the predictors that remained significantly related to the psychological outcomes in multiple regression models. a current or past psychiatric or psychotherapeutic treatment, belonging to a covid- risk group and perceived distress related to the restriction of social contacts were significant predictors in all models (see table for detailed information on all significant predictors for the respective outcome measure). the overall models significantly explained between . % and . % of variance in psychological outcome measures (see table ), all p-values < . . in early , governments worldwide started to implement different forms of public health measures ranging from physical distancing recommendations to stay-at-home orders to prevent further spreading of covid- . for the first time, this study investigated sociodemographic and covid- related factors and, specifically, the role of such different types of governmentally imposed lockdown measures for depressive and anxiety symptoms as well as other health outcomes across all federal states of germany. in the present sample, . % exceeded the cutoff score for a potential depression, . % exceeded the cutoff score for a potential anxiety disorder diagnosis and . % of the sample reported having had a fearful spell during the past weeks. these data are comparable to the prevalence reported in studies conducted in other countries during the covid- pandemic (luo et al., ) . consistent with previous studies from countries around the world (see luo et al., ; vindegaard and eriksen benros, for a review), we found that belonging to a risk group for a severe course of covid- , a current or past treatment due to mental health problems, being unemployed or nonworking, a lower educational level and younger age were associated with negative mental health consequences of the covid- public containment measures. moreover, we revealed that a stronger reduction of social contact, stronger perceived changes in life, and a perceived stay-athome order were associated with poorer mental health. in multiple regressions, common factors that remained significantly related to all outcome measures included a current or past treatment due to mental health problems, distress related to contact restriction and belonging to a risk group for a severe course of covid- . in the present study, we found that a higher level of restrictions due to lockdown measures was associated with more loneliness, higher psychosocial distress and lower life-satisfaction but was not related to anxiety and depressive symptomatology or fearful spells. although the level of restriction due to lockdown measures was not associated with an immediate increase in psychopathological symptoms, more loneliness and higher psychosocial distress might be relevant factors that facilitate or moderate potential negative consequences for mental health. especially loneliness has been associated with an increased risk for several mental disorders and somatic diseases in general (beutel et al. ; holt-lunstad et al. ; valtorta et al. ; luhmann und hawkley ) and during the current pandemic (palgi et al. ; gonzález-sanguino et al. ; luchetti et al. ) . for example, recent studies found that loneliness strongly predicted depressive and anxiety symptoms during covid- -related lockdown measures (palgi et al. ; gonzález-sanguino et al. ) . thus, reducing loneliness might be an important target for prevention programs in order to mitigate negative mental health consequences during these challenging times (holmes et al. ) . moreover, an officially announced stay-at-home order was not related to mental health outcomes. however, about one in four respondents reported to live in a german federal state in which government has imposed a prohibition to leave the apartment without sound reasons (stayat-home order), while objective data indicated that the respective government had not announced such stay-home-order. although there was a stay-at-home order, % of the sample negated that there was an officially imposed prohibition to leave the apartment in their federal state. in contrast to the officially announced stay-at-home order, a perceived stay-at-home order was associated with poorer mental health outcomes. the present findings extend preliminary results from a small cross-sectional study in the us (tull et al., ) in demonstrating that a perceived stay-at-home order was related to more severe depressive and anxiety symptomatology, greater reported loneliness, more fearful spells, greater psychosocial distress and lower life-satisfaction irrespective of whether a stay-at-home order was officially announced or not. importantly, those persons who were affected by a stay-at-home order but took no notice of this order showed no negative mental health consequences. the present finding indicates that misinformation about official stay-at-home orders might have a negative impact on mental health. for example, recent studies found that insufficient information (gonzález-sanguino et al. ) or misinformation ("fake news") on covid- (wang et al. b ) was associated with poorer mental health and well-being (ko et al. ; chao et al. ; gao et al. ) . in contrast, receiving information from health professionals or other experts was not associated with negative mental health consequences (ko et al. ; chao et al. ) . taken together, this suggests that appropriate risk communication during these challenging times of crisis is particularly crucial. thus, it seems important to announce timely, coordinated, transparent and definite instructions in plain language to all persons via official information channels to mitigate confusion, uncertainties, and misinformation regarding public health measures, to prevent negative mental health consequences. the present results should be considered in the light of the following limitations. in the present study, individuals of all ages ( - years) and from all german federal states were recruited. however, as a result of our recruitment method (i.e., convenience sampling methods) older respondents and men were relatively underrepresented in the current sample which limits the generalization of the present results to the general population of germany and other countries. our study exclusively relied on self-report data which might have been subject to memory and recall-biases. moreover, we only assessed internalizing symptoms like depressive or anxiety symptoms, while externalizing symptoms (e.g., anger, aggression, alcohol abuse) might also be affected by public health measures and restrictions (brooks et al., ) . the present study makes a significant contribution to the identification of potential risk groups and the impact of public health measures for immediate mental health consequences during the covid- pandemic. the current findings suggest that the covid- pandemic cause negative consequence for mental health especially in vulnerable groups (e.g. young adults, individuals with a mental disorder) which may need special attention and support by implementing interventions or prevention programs to mitigate long-term consequences for mental health (holmes et al., ) . moreover, in our study, there was little evidence that public health measures per se were associated with immediate mental health impairments. nonetheless, such measures might have unfavorable long-term effects on mental health. for example, lockdown measures have been associated with increased psychological distress and loneliness (tull et al. ) . in line with vulnerability-stress models, it is plausible to assume that such unfavorable feelings not necessarily relate to immediate mental health impairments, but may increase the risk to develop psychopathological symptoms and mental disorders in the future. most importantly, the present data indicate that people"s subjective perceptions of public health measures (i.e., the appraisal of perceived changes in life resulting from lockdown measures and the reduction of social contacts as negative or stressful) seem to be associated with increased psychopathological symptoms. this data underscores the need for appropriate risk communication to prevent insecurity, fear, and confusion and thus prevent negative mental health consequences. moreover, it might be helpful to develop and implement interventions or prevention programs including positive reappraisal or reframing and recommendations to maintain social contacts (e.g., via social media, video calls) in the face of physical distancing and contact restrictions to mitigate the negative effect of public health measures on mental health. . *** . *** . . ** . ** or: odds rations from logistic regressions; β: standardized beta coefficient; all logistic and linear regressions were adjusted for age and gender; ***p<. , **p<. , *p<. or: odds rations from logistic regressions; β: standardized beta coefficient; a nagelkerks r squared; ***p<. , **p<. , *p<. . coronaphobia: fear and the -ncov outbreak loneliness in the general population: prevalence, determinants and relations to mental health the psychological impact of quarantine and how to reduce it: rapid review of the evidence screening for somatization and hypochondriasis in primary care and neurological in-patients mental health consequences during the initial stage of the coronavirus pandemic (covid- ) in spain dimensional and categorical approaches to hypochondriasis multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science. the lancet psychiatry loneliness and social isolation as risk factors for mortality: a meta-analytic review the phq- : validity of a brief depression severity measure anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection depression: a clinical-research approach we're staying at home". association of selfperceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of covid- . the journals of gerontology. series b, psychological sciences and social sciences estimating the reliability of single-item life satisfaction measures: results from four national panel studies the psychological and mental impact of coronavirus disease (covid- ) on medical staff and general public -a systematic review and metaanalysis fear of the coronavirus (covid- ): predictors in an online study quarantine alone or in combination with other public health measures to control covid- : a rapid review. the cochrane database of systematic reviews mental health before and during the covid- pandemic: a longitudinal probability sample survey of the uk population. the lancet psychiatry ucla loneliness scale (version ): reliability, validity, and factor structure a brief measure for assessing generalized anxiety disorder: the gad- the zpid lockdown measures dataset for germany psychological outcomes associated with stay-at-home orders and the perceived impact of covid- on daily life this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors declare no conflict of interest. all authors report no financial relationships with commercial interests. -. * key: cord- -gi zj m authors: gersons, berthold p. r.; smid, geert e.; smit, annika s.; kazlauskas, evaldas; mcfarlane, alexander title: can a ‘second disaster’ during and after the covid- pandemic be mitigated? date: - - journal: european journal of psychotraumatology doi: . / . . sha: doc_id: cord_uid: gi zj m in most disasters that have been studied, the underlying dangerous cause does not persist for very long. however, during the covid- pandemic a progressively emerging life threat remains, exposing everyone to varying levels of risk of contracting the illness, dying, or infecting others. distancing and avoiding company have a great impact on social life. moreover, the covid- pandemic has an enormous economic impact for many losing work and income, which is even affecting basic needs such as access to food and housing. in addition, loss of loved ones may compound the effects of fear and loss of resources. the aim of this paper is to distil, from a range of published literature, lessons from past disasters to assist in mitigating adverse psychosocial reactions to the covid- pandemic. european, american, and asian studies of disasters show that long-term social and psychological consequences of disasters may compromise initial solidarity. psychosocial disruptions, practical and financial problems, and complex community and political issues may then result in a ‘second disaster’. lessons from past disasters suggest that communities and their leaders, as well as mental healthcare providers, need to pay attention to fear regarding the ongoing threat, as well as sadness and grief, and to provide hope to mitigate social disruption. en la mayoría de los desastres que han sido estudiados, la causa subyacente que genera el peligro no persiste por mucho tiempo. sin embargo, durante la pandemia covid- una amenaza a la vida progresivamente emergente es mantenida, exponiendo a todos a variados niveles de riesgo de contraer la enfermedad, morir o infectar a otros. distanciarse y evitar la compañía tiene un gran impacto en la vida social. además, la pandemia covid- tiene un impacto económico enorme para muchos por la pérdida de trabajos e ingreso, lo que está incluso afectando las necesidades básicas como la comida o la vivienda. en adición a esto, la pérdida de seres queridos puede agravar los efectos del miedo y la pérdida de recursos. el objetivo de este artículo es sintetizar a partir de una variedad de literatura publicada, lecciones de desastres pasados para ayudar a mitigar las reacciones psicosociales adversas a la pandemia covid- . trabajos europeos, americanos y asiáticos sobre desastres muestran que las consecuencias a largo plazo tanto sociales como económicas de los desastres pueden poner en peligro la solidaridad inicial. las disrupciones psicosociales, los problemas prácticos y financieros, y los complejos problemas comunitarios y políticos pueden resultar en un 'segundo desastre'. las lecciones de desastres pasados sugieren que las comunidades, sus líderes y también los proveedores de atención en salud mental necesitan prestar atención al miedo en relación a la amenaza en curso, así como a la tristeza y al duelo, y proveer esperanza para mitigar la disrupción social. extensive research on previous disasters has yielded a usable definition of disaster as the result of exposure to a hazard that threatens personal safety, disrupts community and family structures, and results in personal and societal loss, creating demands that exceed existing resources (ursano, fullerton, weisaeth, & raphael, ) . it seems that the current pandemic shares certain characteristics with previous disasters (jacobs et al., ; mcfarlane & van hooff, ; puente, marín, Álvarez, flores, & grassau, ; sundram et al., ; van der velden, bosmans, bogaerts, & van veldhoven, ; watson, brymer, & bonanno, ) . one of the critical challenges is how to use available information and knowledge to inform those who are in charge of the response (fogli & guida, ; krumkamp et al., ) . important sources are the responses to the spanish influenza pandemic (martini, gazzaniga, bragazzi, & barberis, ) and the severe acute respiratory syndrome (sars) epidemic (mak, chu, pan, yiu, & chan, ). specific to the coronavirus disease (covid- ) pandemic is the progressively emerging life threat. this leads, as in other disasters, to a loss of safety; people becoming dependent on each other's behaviour (help and compliance with measures to limit the spread of the virus); the breakdown of infrastructure, with hospitals and healthcare institutions being critically hit and social networks disrupted by lockdowns; and chaos, as illustrated by people hoarding and searching for reliable information, aggravated by the different restrictive measures taken across countries worldwide. finding accurate and reliable sources of information in this pandemic is critical in these circumstances. this has been complicated by the rise of social media as the preferred source of information by some groups in the community, rather than their depending on more carefully edited conventional media outlets (depoux et al., ) . the covid- pandemic and social restrictions have already been shown to impact mental health (fiorillo & gorwood, ; vindegaard & eriksen benros, ) . a sizeable proportion of people recovering from treatment at an intensive care unit (icu) develop posttraumatic stress disorder (ptsd) (davydow, gifford, desai, needham, & bienvenu, ; paparrigopoulos et al., ) . healthcare workers are affected, for whom stressors include confrontation with suffering and death, risk of contracting disease, and moral dilemmas (williamson, murphy, & greenberg, ) . they are at risk of psychological and post-traumatic distress (kisely et al., ) and grief reactions (wallace, wladkowski, gibson, & white, ) . relatives of covid- patients are affected, as they may experience caregiver stress and be confronted with the death of their loved one (hawryluck et al., ) . the initially successful measures taken for containing the virus may be followed by far more socially disruptive consequences related to the psychosocial isolation and the economic consequences (galea & abdalla, ; vigo, thornicroft, & gureje, ; zhang et al., ) . what can we learn from previous disasters? people's response to disasters has previously been described as a phased process (neal, ; raphael, ) . this phased approach enables the identification of the most common reactions to disasters (sundnes, ) . various analyses of these longitudinal models have been conducted and can assist in planning and anticipating the emerging issues in the covid- pandemic response (birnbaum, daily, & o'rourke, ; mcfarlane & williams, ) . in the threat phase, there is an appraisal of the emerging risk, which has been reflected differently between individuals and nations, from the polarity of denial to planning and adaptive action. perhaps, more than in most other disasters, we can see the differential and cascading consequences of the variable willingness to accurately assess an emerging threat. during the initial impact phase, the disaster unfolds, measures to contain its impact are taken, and an emotional outcry is manifested. however, covid- is a continuous disaster and responses to this disaster may vary among different populations as the disaster unfolds (dara, ashton, farmer, & carlton, ) . indeed, communities and countries may differ significantly in the extent to which the spread of the disease is brought to a halt. this, in turn, may lead to great variations in the sense of threat. the covid- pandemic shows a protracted impact phase: expressions of sadness and anger are muted, while powerlessness and alertness remain. the subsequent, in this case less prominent, honeymoon phase is characterized by feelings of relief and connection that are marked by spontaneous acts of solidarity and connectedness, such as clapping for healthcare providers. without a vaccine or established evidence-based treatment, the threat is still ongoing. the disillusion phase reactions may also vary between populations, in part driven by the extent of fractious social media debates and the politicization of the response options, such as whether to wear or not to wear face masks. people have become increasingly tired of chaos and fear, and those affected by the pandemic, such as slowly recovering covid- patients and the families of the deceased, will increasingly feel forgotten. the spotlight progressively will fade out on healthcare workers and caregivers in nursing homes who worked so hard without the necessary equipment. people suffering from diseases such as cancer and cardiovascular disease, and their caregivers, in families who have experienced restricted access to the required health services during lockdown, will have major concerns about their health. others are hit by the economic impact and many will long for the return of normal affective social relations. this phase therefore carries the risk of splintering society between groups that are affected differently, thereby creating a breeding ground for a 'second disaster' to take place (erikson, ; yzermans & gersons, ) . the final phase, the reintegration phase, still seems far away. a further important dynamic of this disaster and its phases is that the source of the threat has not lessened, and a constant reappraisal and adaptation to the risks is required as the impact phase will not come to an end until a vaccine has been developed or the virus has been eliminated from the community. what do previous disasters teach us about containing psychosocial impacts? in response to the / attacks in the usa, five essential elements of interventions were identified to be promoted as part of the disaster response, ranging from provision of community support and public health messaging to clinical assessment and intensive intervention (hobfoll et al., ) . the five elements are summarized in table and applied to the covid- pandemic. first, to promote a sense of safety; for example, by taking measures to limit the spread of the virus and disseminating knowledge about the virus. in the covid- situation, eliminating the disease threat may not be possible, as herd immunity and a vaccine are yet to come. secondly, for authorities and experts to promote calming. during the pandemic this can be achieved by clearly explaining measures, considering the implications involved, and showing genuine compassion. thirdly, to promote a sense of self-and collective efficacy. self-efficacy is the individual's belief that his or her actions generally lead to positive outcomes, and this can be extended to collective efficacy, which is the sense that one belongs to a group that is likely to experience positive outcomes. efficacy beliefs result from accurate information appraisal, considered decision making, behavioural skills, and practised repertoires, as well as access to resources (patterson, weil, & patel, ) . thus, during the covid- pandemic, leadership may enhance collective efficacy by communicating the effects of the measures, showing genuine empathy, sharing the economic burdens, promoting solidarity, and promoting activities that are conceptualized and implemented by the community, such as religious activities and mourning rituals. fourthly, to promote connectedness by preventing disadvantage or exclusion of specific groups, and adjustment of social services to the needs of the most vulnerable groups. fifthly, to instil realistic hope by providing perspective and mitigating feelings of powerlessness and discouragement. sources of hope include effective threat appraisal, self-reliance, demonstrated benefits of scientific appraisal and rational action, religious beliefs, belief in a responsive government, and superstitious beliefs. indeed, the covid- pandemic has seen a rise in religious coping (bentzen, ) . do these elements translate differently to the different affected groups in the process of setting policy and designing intervention strategies? for patients and healthcare workers, the disaster experience involves intense fear of one's own death or the death of someone close, and promoting safety and calming are the first priorities. this requires the active and effective resourcing of the health system, which includes the provision of high-quality personal protective equipment and ensuring the welfare and protection of families of healthcare workers. proper financial support for healthcare workers who become sick and adequate compensation for the families of those who die from the infection are critical. for people experiencing the loss of loved ones or economic needs of the population amid the pandemic actions required by authorities and experts to mitigate the impact of covid- sense of safety immediate actions of public health measures to limit the spread of the infection delivery of reliable information for the general population and various groups about the disease effective resourcing of required medical equipment calming active communication and constant explanation of the actions needed to contain the spread of the infection to the population compassion of authorities towards victims and various groups affected by the pandemic sense of self-and collective efficacy communication of plans on coping with the economic and social effects of the pandemic stimulating in everyone the sense that one belongs to a group promotion of solidarity and community activities, such as mourning or religious rituals connectedness active implementation of digital services in education, public institutions, and other services to ensure social functioning of different groups ensuring the functioning of social services, and adjustment of services to the new models of care for vulnerable groups acknowledgement of loss and sadness in the community hope providing perspective and mitigating feelings of powerlessness and discouragement communication about progress of treatment and vaccine developments symbolic rituals and events to promote resilience facilitation of various community, charity, and business initiatives targeted towards a better future losses, the disaster causes isolation and despair, and promoting connectedness and instilling hope are paramount. promoting a sense of self-and collective efficacy is a key priority for all affected groups. collective failure may create or deepen societal splits along historical and intergenerational fault lines, resulting in a second disaster. this variety in affected groups creates a challenge in dealing with the pandemic's consequences. decision makers may be tempted to focus more on certain affected groups, to the detriment of others, thus creating a hierarchy of suffering. with growing tension, there is a risk that affected groups will come to stand directly opposite each other while losing confidence in the government. a split along intergenerational lines carries particular risks. counterbalancing disillusionment is possible when loss and grief are given a place and when government and businesses explicitly create prospects for those affected economically. efforts are crucial to prevent and treat the mental health impact of the pandemic in all sectors of society, including healthcare workers . care providers in hospitals and residential care organizations for elderly people need peer support, spiritual care, and access to mental healthcare for treatment of burnout, ptsd, moral injury, and other conditions. aftercare for recovered covid- patients needs to include access to specialized treatment of icu-treatment-related ptsd. there is also the risk of post-infection syndromes including chronic pain, depression, and fatigue (moldofsky & patcai, ) . specific attention needs to be paid to the management and treatment of bereaved individuals. grief interventions taking into account the complex circumstances of the loss, such as ritual omissions and other cultural and intergenerational determinants of meaning attribution (smid, ) , may support meaning reconstruction following loss and thereby contribute towards increasing connectedness and inspiring hope. the pandemic affects the traditional means of delivery of psychosocial services, including psychological treatments for mental disorders. this causes challenges in the delivery of the available evidence-based practice models, as novel digital models of care need to be developed and implemented to ensure access to mental health services in various phases of the pandemic (javakhishvili et al., ) . while a number of studies on the effects of the covid- pandemic are emerging, this disaster is still unfolding, with a lot of uncertainty about its course. based on the studies of previous disasters, we identified possible psychological responses to the covid- pandemic. we also foresee that psychosocial disruptions, practical and financial problems, and complex community and political issues associated with the pandemic could result in a second disaster. lessons from past disasters suggest that communities and their leaders, as well as mental healthcare providers, need to address the different needs of various populations in society. in particular, there is a need to pay attention to fear regarding the ongoing threat, as well as sadness and grief; and to provide a sense of safety, connectedness, and hope to mitigate social disruption. we have no commercial interest to disclose. we have not asked for or received any funding for this study. in crisis, we pray: religiosity and the covid- pandemic. london: centre for economic policy research and evaluations of the health aspects of disasters, part iii: framework for the temporal phases of disasters worldwide disaster medical response: an historical perspective posttraumatic stress disorder in general intensive care unit survivors: a systematic review the pandemic of social media panic travels faster than the covid- outbreak the wake of the 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disturbances: a longitudinal study the differential outcomes of coronavirus disease in low-and middle-income countries vs high-income countries covid- pandemic and mental health consequences: systematic review of the current evidence grief during the covid- pandemic: considerations for palliative care providers postdisaster psychological intervention since / covid- and experiences of moral injury in front-line key workers toxic turmoil: psychological and societal consequences of ecological disasters mental health and psychosocial problems of medical health workers during the covid- epidemic in china key: cord- - ckdr authors: maalouf, fadi t.; medawar, bernadette; meho, lokman i.; akl, elie a. title: mental health research in response to the covid- , ebola, and h n , outbreaks: a comparative bibliometric analysis date: - - journal: j psychiatr res doi: . /j.jpsychires. . . sha: doc_id: cord_uid: ckdr introduction: both the covid- pandemic and its management have had a negative impact on mental health worldwide. there is a growing body of research on mental health as it relates to the pandemic. the objective of this study is to use bibliometric analyses to assess the mental health research output related to the covid- pandemic and compare it to that of the west africa ebola and h n outbreaks. methodology: we performed comprehensive searches in embase, pubmed, and scopus databases, and included all types of documents related to the three outbreaks published since the respective beginnings up to august , . results: despite the shorter time since the beginning of the covid- pandemic, relative to ebola and h n , we found a much greater number of mental health documents related to covid- (n= , ) compared to the two other outbreaks ( for ebola and for h n ). the proportion of documents in the top % journals was % for covid- , % for ebola, and % for h n . authors affiliated with institutions located in high-income countries published or contributed to % of all documents followed by authors from upper-middle-income countries ( %), lower-middle-income countries ( %), and low-income countries ( %). approximately % of the documents reported receiving funding and % were the product of international collaboration. conclusion: mental health research output is already greater for covid- compared to ebola and h n combined. a minority of documents reported funding, was the product of international collaboration, or was published by authors located in low-income countries during the three outbreaks in general, and the covid- pandemic in particular. after the emergence of pneumonia of unknown causes in late in wuhan, china, a new coronavirus, sars-cov , was identified. on march , , the world health organization (who) announced alarming concerns regarding the new virus and characterized it as the covid- pandemic (neilson, woodward, mosher, ; who, c) . as of august , , countries, areas, or territories were swept by the pandemic, , , people have been infected, and , died as a result of the virus (who) (who, a) . the death rate reached % in some countries (worldmeter, b) . distribution of confirmed cases varies by continent and countries, but the bulk extends over the americas and asia, with , , and , , infected individuals, respectively (worldmeter, d) . according to the scopus database, on august , , there were over , articles, letters, editorials, notes, reviews, and case reports published on covid- and, per pubmed, thousands more were accepted for publication. the impact of the covid- pandemic on mental health has been of immense interest to international health organizations (who, b), national health agencies (cdc, ) , and psychiatric and other mental health researchers. recently published studies reported an increasing rate of psychological distress, traumatization, and suicide in relation to covid- (reger et al., ) . for example, in an online survey in china, % of respondents reported moderate to severe anxiety symptoms, while % reported depressive symptoms . research has also found a negative impact of covid- public health interventions on mental health. for example, the strictly implemented measures of social distancing led to various negative psychological consequences associated with a prolonged quarantine duration, fear of catching the infection, disturbed routine, and lack of adequate supplies and j o u r n a l p r e -p r o o f information about the virus (brooks et al., ) . the post-pandemic phase is even more unsettling due to the increasing rates of post-traumatic stress disorder (ptsd) and other mental health sequelae (dutheil et al., ) . mental health researchers have also been interested in the impact of other infectious disease outbreaks on mental health and the mental health response to those outbreaks. two prominent examples are the h n influenza outbreak in and the ebola virus disease (evd) outbreak in . for example, one study reported on fear and anxiety as common reactions during the h n pandemic (taha et al., ) and another study related to evd reported that the burden of the disease on mental health continued to linger in the aftermath (reardon, ) . interestingly, while a high level of h n -related anxiety was associated with compliance to preventive measures (bults et al., ) , fear of exposure or stigmatization during the evd epidemic prevented individuals from seeking help and thus hastened viral transmission (o'leary et al., ) . covid- , h n , and evd vary in their epidemiological characteristics and general prevalence of associated mental distress and disorders. we have summarized these differences in table . (lau et al., ) depression - %, anxiety . - . %, ptsd % (cénat et al., ) depression %,- %, anxiety - %, insomnia - % (rossi et al., ; shi et al., ) j o u r n a l p r e -p r o o f before the covid- outbreak, humanity faced two other coronavirus epidemics; namely, sars in and mers in . out of the five outbreaks that occurred during the past two decades, covid- , evd, and h n have infected more people worldwide as compared to sars and mers which were associated with elevated case fatality rates of % and %, respectively (sarukhan, ) . the current study focuses on the most recent coronavirus outbreak (i.e., covid- ), and evd and h n . our objective is to use bibliometric analyses to assess the mental health research output related to the covid- pandemic and compare it to that of evd and h n outbreaks. we specifically aimed to identify the publications' numbers, types, venues, origins, levels of funding, and levels of collaboration. we used embase, pubmed, and scopus databases to identify relevant documents. to be as inclusive as possible, we carried out comprehensive searches for documents that included in the title, abstract, or keywords fields both terms and phrases related to for each of the three infectious diseases, we extracted the following data: -number of documents by disease; -number of documents published in open access format, as a measure of accessibility; -number of documents by country, based on affiliation information provided for each document. we gave equal full credit for each country represented in each document. we also specified the number of documents by country for each outbreak alone as well as the total number of documents by country for the three outbreaks together; -number of documents by countries' income. we categorized countries into four groups according to the world bank classification: high-income countries, upper-middle-income countries, lower-middle-income countries, and low-income countries. we then calculated for each outbreak, the total number of documents in each of the four income categories; -proportion of documents in high impact journals, defined as the top % journals in their respective fields per scopus's citescore; j o u r n a l p r e -p r o o f -proportion of documents with authors from more than one country, as a measure of international collaboration; and -percentage of documents receiving internal or external funding as recorded by the scopus database. we exported the data and analyzed them using microsoft excel and access . we analyzed all indicators using frequency analysis and cross-tabulations where necessary. we compared findings for the three outbreaks, then compared them by country income level and funding, and finally assessed the patterns of collaboration between countries. the assessment of international collaboration included the proportion of documents with authors from more than one country and social network analyses using the vosviewer software. where necessary, we supported our claims by comparing results of outbreakrelated mental health research against those of the larger fields of "psychiatry and mental health" and "medicine" as defined by scopus. in scopus, the field of "psychiatry and mental health" is composed of active journals and "medicine" of , such journals. the number of documents published on mental health aspects of the three outbreaks was as follows: , on covid- in less than a year since the first case was officially reported, on west african ebola since late , and documents on h n since . when examining research productivity by country ( leone, liberia, and uganda and no lmic country is among the topmost published on any outbreak (see table ). we should emphasize here that about % of the total publication on the mental health aspects of covid- were about health care workers as compared to % of the evd publications and % of publications on h n (see figure ). the proportion of outbreak-related mental health documents published in the top % journals per scopus's citescore was % for covid- , % for evd, and % for h n . these percentages for outbreak-related mental health were, in the cases of covid- and h n , considerably higher than the percentages for "psychiatry and mental health" and "medicine" overall research fields (see table ). concerning research accessibility, the proportion of outbreak-related mental health documents published in open access format was % for covid- , % for ebola, and % for h n . these percentages for outbreak-related mental health were remarkably larger than the proportions for psychiatry, mental health, and medicine research fields in general (see table ). source: scopus (august ). as shown in table , of all published documents, the proportion of outbreak-related mental health documents reporting funding was % for covid- , % for evd, and % for h n . during covid- particularly, the percentage of funded "outbreak-related mental j o u r n a l p r e -p r o o f health research" was remarkably lower than the funding received for "psychiatry and mental health" research ( %) and "medicine" research ( %). in terms of the proportion of documents with authors from more than one country, % of mental health research related to all three diseases had multinational co-authorship. while % of evd mental health publications were the product of international collaboration, only % of the total covid- mental health research and % h n mental health-related publications resulted from such collaboration. the bibliometric approach used in the current study is comprehensive as we included all types of documents available in any language from three distinct, comprehensive databases: embase, pubmed, and scopus. additionally, the choice of phrases and terms related to mental health and each of the outbreaks was exhaustive. unlike prior analyses of the scientific literature on coronaviruses, ours did not limit to records in english nowakowska et al., ; tao et al., ; zhai et al., ) or english and chinese only (yu et al., ) . we additionally extracted records from more than two databases (haghani et al., ; liu et al., ) and included editorials, commentaries, letters, case reports, news, and narrative reviews yu et al., ) . in addition to looking at the number and countries of origin of publications, we also examined indicators related to international collaboration, funding, and research quality. , namely, the trend in mental health research, and compared the findings with two prior distinct viral outbreaks. our study, however, has a couple of limitations. although we tried to be as inclusive as possible using three different databases, there may be publications that are not captured by embase, pubmed, and scopus. also, since the covid- pandemic is still evolving, our results do not represent the complete course of the fast-growing literature of the current pandemic. it was not surprising that the number of publications on covid- related mental health publications was much higher than that of the other two outbreaks combined. these results are explained by the relative magnitude of the different outbreaks. for example, the death toll registered for covid- during the first six months of the outbreak exceeded the total deaths during the first two years of the evd epidemic and is close to the estimated death toll during months of the h n pandemic (cdc, , (cdc, , a (cdc, , b worldmeter, c) . furthermore, unlike the more localized evd epidemic (cdc, b), the transcontinental spread of the current covid- pandemic (worldmeter, b) , although similar in its geographical distribution to the h n pandemic (cdc, ), has precipitated an unusual global economic, social, and geopolitical crises (nicola et al., ) . these have resulted in mental health distress among the general public (alradhawi et al., ) . the proportion of publications about health care workers was higher for evd as compared to the other two outbreaks. this may be due to the high fatality rate of evd and the stigma associated with it as compared to covid- which puts health care workers at higher risk for mental health disorders (cénat et al., ; rossi et al., ; shi et al., ) . we also found a gradual increase in open access publications in mental health research during infectious outbreaks from % during h n up to % during the covid- pandemic. although a similar trend was observed for publications in medicine and mental health in general, the proportion of open access publications in mental health aspects of covid- was double that observed for mental health in general (piwowar et al., ) . besides seeking higher citations associated with open access articles (piwowar et al., ) , researchers likely aimed at making their research results as widely accessible as possible during outbreaks in general and covid- pandemic in particular (eysenbach, this is also in-line with our findings that only a small minority ( %) of research about mental health in any of the three outbreaks included authors from low and low-middleincome countries. indeed, it has been previously reported that only % of the mental health literature is published from regions of the world that account for over % of the global population (helal et al., ; patel and kim, ; zeinoun et al., ) . acceptance bias, low submission rate, and low quality of submitted research are likely reasons for these geographical disparities (patel and sumathipala, ) . the proportion of publications on mental health-related to the outbreaks that reported receiving funding was lower than the proportion of publications on general mental health that reported receiving funding. this difference may be because, amid an outbreak, investigators do not have time to seek funding and seem to prioritize getting much-needed j o u r n a l p r e -p r o o f evidence out to the scientific community over waiting for projects to get funded. in addition, in many parts of the world, mental health is still not a research priority for major funding agencies (maalouf et al., ) . interestingly, however, despite receiving less funding, the proportion of publications on mental health aspects of the outbreaks published in the top % journals was remarkably higher than that of medicine and mental health overall. despite the time lag between the first studies on all three outbreaks in general and the first studies on mental health aspects of the outbreaks in particular, research output in the latter area follows an upward trend similar to that of other research areas. indeed, previous bibliometric analyses found increased output in microbiological, epidemiological, and clinical research of coronaviruses that peaked one to two years following sars and mers outbreaks (haghani et al., ; nowakowska et al., ; tao et al., ) . the gradual increase in mental health research over time is important for all pandemics, particularly covid- , given the dire need for generating evidence to guide best practices. the impact of the covid- pandemic extends beyond infected individuals and healthcare workers. while quarantine is a common denominator for all infectious outbreaks (tognotti, ) , widespread lockdown and social distancing were essential public health tools used in the covid pandemic (news, ) . on the one hand, strict lockdown measures increased worries about physical health, anger, impulsivity, suicidal ideations as well as symptoms of anxiety, depression, insomnia, and ptsd among mentally ill patients. on the other hand, access to direct emergency and outpatient psychiatric care was reduced (hao et al., ) . consequently, mental health practitioners and policymakers called for j o u r n a l p r e -p r o o f research on regulations and implementations of alternative clinical interventions, such as telepsychiatry (kannarkat et al., ; shore et al., ) . this is the first bibliometric analysis of mental health research comparing research aspects of the three infectious disease outbreaks that took place over the last decade or so, namely h n , ebola, and covid- . the analysis shows rapid exponential growth in the number of mental health research during outbreaks. our study also highlights the paucity of funding, collaboration, and contribution of lic to mental health research during all outbreaks in general but more importantly during the current covid- pandemic. albeit the increased awareness of the short-and long-term psychological impacts of infectious outbreaks that lead to better representation of mental health research in the top % journals, efforts need to be aggregated to fill the prevailing gaps in mental health research. anticipating a mental health pandemic, experts have called for action for mental health research (hoffmann, ) . that research should prioritize key questions, produce highquality studies, and involve international multidisciplinary collaboration (holmes et al., ) . the results of this study could help experts set a roadmap for future covid- related mental health research and contribute to the international response to the current pandemic. j o u r n a l p r e -p r o o f effects of the covid- pandemic on mental wellbeing amongst individuals in society-a letter to the editor on "the socio-economic implications of the coronavirus and covid- pandemic: a review sars-cov, mers-cov and now the -novel cov: have we investigated enough about coronaviruses? -a bibliometric analysis the psychological impact of quarantine and how to reduce it: rapid review of the evidence perceived risk, anxiety, and behavioural responses of the general public during the early phase of the influenza a (h n ) pandemic in the netherlands: results of three consecutive online surveys h n early outbreak and disease characteristics h n : overview of a pandemic impact of h n pandemic (h n pdm virus ebola outbreak in west africa cdc, . coronavirus disease (covid ) stress and coping prevalence of mental health problems in populations affected by the ebola virus disease: a systematic review and meta-analysis coronavirus disease (covid- ): a machine learning bibliometric analysis ptsd as the second tsunami of the sars-cov pandemic r : how scientists quantify the intensity of an outbreak like coronavirus and its pandemic potential the scientific literature on coronaviruses, covid- and its associated safety-related research dimensions: a scientometric analysis and scoping review do psychiatric patients experience more psychiatric symptoms during covid- pandemic and lockdown? a case-control study with service and research implications for immunopsychiatry the representation of low-and middle-income countries in the psychiatric research literature covid- : be ready for the coming mental health pandemic multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science mobilization of telepsychiatry in response to covid- -moving toward (st) century access to care avoidance behaviors and negative psychological responses in the general population in the initial stage of the h n pandemic in hong kong coronavirus disease (covid- ): an evidence map of medical literature mental health research in the arab region: challenges and call for action coronavirus: the world in lockdown in maps and charts a comprehensive timeline of the coronavirus pandemic at months, from china's first case to the present the socio-economic implications of the coronavirus and covid- pandemic: a review when science goes viral: the research response during three months of the covid- outbreak fear and culture: contextualising mental health impact of the - ebola epidemic in west africa contribution of low-and middle-income countries to research published in leading general psychiatry journals international representation in psychiatric literature: survey of six leading journals the state of oa: a large-scale analysis of the prevalence and impact of open access articles ebola's mental-health wounds linger in africa suicide mortality and coronavirus disease -a perfect storm covid- pandemic and lockdown measures impact on mental health among the general population in italy ebola: two years and , deaths later. global health lessons from an epidemic prevalence of and risk factors associated with mental health symptoms among the general telepsychiatry and the coronavirus disease pandemic-current and future outcomes of the rapid virtualization of psychiatric care intolerance of uncertainty, appraisals, coping, and anxiety: the case of the h n pandemic covid- will stimulate a new coronavirus research breakthrough: a -year bibliometric analysis lessons from the history of quarantine, from plague to influenza a immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china emergencies preparedness, response: pandemic (h n ) coronavirus disease (covid- ) pandemic mental health and psychosocial considerations during the covid- outbreak who, c. who timeline -covid- estimating mortality from covid- worldmeter, a. coronavirus incubation period countries where covid- has spread covid- situation update worldwide, as of assessment of the quality of systematic reviews on covid- : a comparative study of previous coronavirus outbreaks the arab region's contribution to global mental health research ( - ): a bibliometric analysis research progress of coronavirus based on bibliometric analysis mental health'/exp/mj or 'mental health care'/exp/mj or 'mental health service'/exp/mj or 'mental disease'/exp/mj or 'mental health':ti,ab,kw or 'mental disease*':ti,ab,kw or 'mental disorder*':ti,ab,kw) and: . (' h n influenza'/exp or 'influenza a (h n )'/exp or h n *:ti,kw or 'novel influenza virus*':ti,kw or 'pandemic influenza':ti,kw or ebola hemorrhagic fever'/exp/mj or 'ebolavirus'/exp/mj or ebola*:ti,ab,kw) or 'coronavirus disease- ' or 'coronavirus- ' or 'covid ' or 'covid- ' or 'ncov ' or 'ncov- ' or 'novel coronavirus ' or 'sars coronavirus '/exp or 'sars coronavirus ' or 'sars-cov ' or 'sars-cov- ' or 'severe acute respiratory syndrome coronavirus '/exp or 'severe acute respiratory syndrome coronavirus ') or (((coronavirus:ti or 'corona virus':ti or covid*:ti,ab,kw or (wuhan:ti,ab,kw and coronavirus:ti,ab,kw) or (hubei:ti,ab,kw and coronavirus:ti,ab,kw)) not ( e*:ti or 'avian coronavirus':ti or bovine:ti or 'bovine coronavirus':ti,ab,kw or calves:ti,ab,kw or camel*:ti or 'canine coronavirus':ti or covidence:ti,ab,kw or covidien*:ti,ab,kw or 'feline coronavirus':ti or 'feline enteric coronavirus':ti or 'hcov- e':ti or 'infectious bronchitis':ti or 'mouse coronavirus':ti or 'murine coronavirus':ti or 'murine hepatitis virus':ti,ab,kw or nl :ti or oc :ti or porcine:ti or sads*:ti,ab,kw or swine:ti or 'turkey coronavirus':ti,ab,kw)) and [ - ]/py)) not ispor:nc pubmed (mental health[mesh major topic] or mental health services -coronavirus" or " -cov" or " -ncov" or " -new coronavirus" or " -novel coronavirus" or "corona virus disease- clinical psychology" in the database, research and covid- , ebola, and h n and all documents that included in their titles keywords related to "mental disorders" and "mental health" regardless of the subject categories of journals in which they were published ( )) and: . title-abs(h n *) or authkey(h n ) avian coronavirus" or bovine or camel* or "canine coronavirus" or "feline coronavirus" or "feline enteric coronavirus" or "hcov- e" or "infectious bronchitis" or "murine coronavirus" or nl or oc or porcine or swine) or title-abs-key("bovine coronavirus" or calves or covidence or covidien* or "murine hepatitis virus the authors declare no conflict of interest.j o u r n a l p r e -p r o o f key: cord- -yt k m authors: han, rachel h.; schmidt, morgan n.; waits, wendi m.; bell, alexa k. c.; miller, tashina l. title: planning for mental health needs during covid- date: - - journal: curr psychiatry rep doi: . /s - - - sha: doc_id: cord_uid: yt k m purpose of review: the ability to effectively prepare for and respond to the psychological fallout from large-scale disasters is a core competency of military mental health providers, as well as civilian emergency response teams. disaster planning should be situation specific and data driven; vague, broad-spectrum planning can contribute to unprepared mental health teams and underserved patient populations. herein, we review data on mental health sequelae from the twenty-first century pandemics, including sars-cov (covid- ), and offer explanations for observed trends, insights regarding anticipated needs, and recommendations for preliminary planning on how to best allocate limited mental health resources. recent findings: anxiety and distress, often attributed to isolation, were the most prominent mental health complaints during previous pandemics and with covid- . additionally, post-traumatic stress was surprisingly common and possibly more enduring than depression, insomnia, and alcohol misuse. predictions regarding covid- ’s economic impact suggest that depression and suicide rates may increase over time. summary: available data suggest that the mental health sequelae of covid- will mirror those of previous pandemics. clinicians and mental health leaders should focus planning efforts on the negative effects of isolation, particularly anxiety and distress, as well as post-traumatic stress symptoms. although the coronavirus (covid- ) pandemic initially resulted in roughly new covid- -related listings each week on the pubmed.gov website, very few of these publications addressed the practical matter of how mental health providers and leaders should specifically plan for the post-pandemic mental health tsunami that many predict is inevitable [ ] . the purpose of this article, written from the perspective of military medical planners, is to present available data on the prevalence of specific mental health concerns and conditions from previous recent pandemics and covid- , as well as to provide data-informed recommendations for meeting the psychological needs of affected individuals. historically, pandemics have had significant ramifications for psychological stress and mental health. the global reach and protracted course are unique to pandemics and other infectious disease outbreaks compared with other types of disasters. prolonged social distancing protocols, increased unemployment rates, and economic stress have the potential to create an unprecedented mental health crisis. from prior disasters, military researchers have learned that affected people tend to do well over time with minimal psychiatric sequelae [ ••]. however, there is still concern for residual psychopathology, including anxiety, depression, bereavement, and posttraumatic stress. among healthcare workers (hcws) in particular, decreased social support and isolation may be expected even while at work due to assignment to unfamiliar hospital areas, requirement for personal protective equipment (ppe) that obscures identities, and inability to gather in groups [ physical distancing, while important to protect against physical illness, often results in social isolation and loneliness, especially for vulnerable groups. it is well known that social isolation has a detrimental effect on mental health outcomes. both living alone and feelings of loneliness have been associated with increased suicidal ideation and suicide attempt [ ] . further, since covid- was declared a public health emergency, many employees have been either laid off or furloughed, causing economic anxiety and distress. many schools and daycares have also physically closed indefinitely, forcing families with children to take time off from work to provide childcare and take on the additional burden of assisting with virtual learning. in the past, times of economic downturn have been associated with increased rates of completed suicide in high-income countries [ ] . accordingly, we anticipate a rise in mental healthcare usage and increased susceptibility of certain groups to mental illness and its consequences as the pandemic continues. we conducted a rapid review of the twenty-first-century pandemics with the goal of establishing a preliminary projection of mental health needs related to covid- . since formal preferred reporting items for systematic reviews and meta-analyses (prisma) guidance for rapid reviews is currently pending, we referred to a published analysis of the most common rapid review elements while conducting our review [ ] [ ] [ ] . questions we hoped to answer included the following: what mental health sequelae emerged following pre-covid- twenty-first-century pandemics? and what does preliminary data on the psychological effects of covid- reveal? our rapid review included papers published from january to july on pubmed, as well as searches of various gray literature sources for guidelines, position papers, and journalistic reports. search strategies were structured around three major concepts: pandemics, mental health, and data analysis. a combination of the following keywords in the title and/or abstract was used in searches of literature on the southeast asian respiratory syndrome (sars), h n influenza (h n ), middle eastern respiratory syndrome (mers), ebola, and covid- pandemics: mental health or mental illness or psychiatry or psychology or therapist or ptsd or posttraumatic or post-traumatic stress disorder or behavioral health or anxiety [disorder] or gad or depression/depressed or complex grief and data analysis or statistic* or prevalence or percentage or increase or decrease. peer-reviewed articles addressing the mental health sequelae during or following the listed pandemics were included. other inclusion criteria were populations of all age groups, from any location, and published in english. articles that reported physical health rather than mental health were excluded. articles that reported on preventative behaviors were also excluded. additional exclusion criteria included case studies, abstracts, commentaries, and opinion pieces. titles and abstracts of the identified literature were first reviewed. literature not complying with the search criteria was excluded. the full text was obtained for articles in which inclusion/exclusion criteria were not clear, and references were independently screened. the findings presented chronologically below are based on information pertaining to recent pandemics, including severe acute respiratory syndrome (sars), h n influenza virus (h n ), middle eastern respiratory syndrome (mers), ebola, as well as the current covid- pandemic (see fig. ). findings for children pertaining to covid- are discussed separately given the unique psychological conditions considered for this population. the sars coronavirus epidemic spread through countries in , resulting in over cases, largely affecting asian countries. community-based surveys revealed that during the outbreak, almost % of community populations experienced increased stress, with % experiencing post-traumatic stress symptoms [ ] . a taiwan-based study showed . % of a nationwide sample had a psychiatric morbidity measured by the brief symptoms rating scale [ ] . hcws were also significantly affected due to risk of exposure, with higher ratings of stress and depressive and anxious symptoms persisting a year post-outbreak [ ] . six percent self-medicated with alcohol to cope with these feelings [ ] . having to quarantine also caused a significant increase in depressive symptoms [ ] . nonetheless, no rise in dsm-iv psychiatric diagnosis was found years later [ ] . elderly populations appeared to be at greater risk of suicide, with a % increase in completed suicides among adults aged and older in hong kong in at the peak of sars cases. further analysis led to identification of certain factors, including fear of contracting sars, increased isolation, disruption of social life, and increased chronic disease burden [ ] . finally, survivors had significant levels of psychiatric morbidity after the epidemic. prevalence of any psychiatric disorder at long-term follow-up was - . %, with % of survivors carrying a diagnosis of post-traumatic stress disorder (ptsd) and % having a depressive disorder [ , ] . in the usa, the h n influenza virus was first detected in april . by april , the centers for disease control and prevention (cdc) estimated about . million cases, , hospitalizations, and , deaths due to the virus in the usa alone. the published data on behavioral/ psychological responses focuses mostly on the anxiety prevalent due to uncertain conditions among hcws [ ] . in guangzhou, china, . % of university students reported feeling panicked, depressed, or emotionally disturbed as a result of h n , and % worried about them or their family catching the virus [ ] . hcws in greece experienced moderately high anxiety about the pandemic, with their predominate concern being infection of family and friends and subsequent health consequences. interestingly, perceived sufficiency of public information about h n was associated with reduced degree of worry [ ] . this finding was consistent with findings among hcws in japan, where workers who were less frequently provided information about the pandemic felt less protected than their more informed colleagues. in addition, fig. flow diagram for review of pandemic mental health outcomes japanese hospital workers in higher risk environments felt more anxious and exhausted [ ] . the middle east respiratory syndrome (mers) first emerged in saudi arabia in and spread throughout the arabian peninsula, affecting over individuals. while person-to-person transmission was limited, hcws were deemed to be at higher risk for contracting mers, with a case fatality rate of around - %. a south korean study of quarantined individuals showed . % had feelings of anxiety during quarantine, but only % had persistent anxiety at - months after release. risk factors for anxiety included inadequate supplies, somatic symptoms related to mers, financial loss, social media use, and a history of psychiatric illness [ ] . the - ebola outbreak in west africa spread rapidly due to inadequate healthcare facilities, lack of trained staff, and poor health literacy, leading to inability to receive care from hcws who were often exposed to and contracted the disease. one year after onset in sierra leone, a study on the mental health impact on the general population revealed a prevalence of almost % of any anxiety or depression symptoms via patient health questionnaire- (phq- ). prevalence of any ptsd symptom was %, as measured by six items from the impact of events scale revised. of note, only % met the clinical cut-off for anxiety and depression. for ptsd, % met levels of clinical concern, and % met probable diagnosis. factors associated with higher reporting of symptoms included region of residence, experiences with ebola such as knowing someone quarantined, and perceived threat [ ] . the outbreak reached spain, the uk, and the usa as a result of globalization and international travel, threatening global security and the world economy. in late , the us military sent troops to west africa to help curb this epidemic. a review examining the potential psychological impact of this deployment qualitatively predicted that deployed service members would return with clinically significant problems, including psychological distress, alcohol/drug use, post-traumatic stress disorder, anxiety, and most significantly depression. they also suggested that among militaryspecific sociodemographic factors (young, single, no family, less work experience, lower educational levels and income) predicted poorer outcomes [ ] . the second deadliest ebola outbreak was in and is currently ongoing. as a result, in the democratic republic of the congo, mental health professionals have joined response teams to provide psychological treatments to patients dealing with anxiety and death [ ] . a systematic review of the prevalence of mental health problems in populations affected by the outbreak revealed that approximately % of individuals exposed to the virus (survivors, families, communities, healthcare workers, safe and dignified burial teams) were diagnosed with depression [ ] . on may , , the united nations (un) policy brief on "covid- and the need for action on mental health" noted concerns over widespread psychological distress, referencing three sources [ ] . the first was a study in china claiming to be the first nationwide large-scale survey of psychological distress in the general population. in total, , responses to a self-reported questionnaire sought to identify demographic characteristics associated with higher distress levels. the authors suggested that the country's response to the covid- pandemic, including implementation of strict quarantine measures, triggered a wide variety of psychological problems, such as panic disorder, anxiety, and depression [ •] . the second was a study in iran that used the same survey as above. based on responses, the authors concluded that predictors of distress may vary across countries, citing differences in age and education that predicted distress in china but not in iran (younger age and higher education correlated with higher distress in china) [ •] . the third was a survey from april by the kaiser family foundation revealing that % of adults in the usa believed the pandemic had affected their mental health. of note, % reported increasing alcohol or drug use. sixtyfour percent of those who reported stress and worry around covid- come from front-line hcws and their families and % from americans who experienced an income loss [ ] . as recently as late june, % of us adults reported struggling with mental health issues or substance use, with % endorsing anxiety/depressive symptoms, % endorsing traumarelated symptoms, % endorsing starting or increasing substance use, and % seriously considering suicide [ ••] . in china, the immediate psychological effects of the covid- outbreak were more specifically studied in the general population. using the impact of event scale-revised (ies-r), . % reported moderate or severe psychological impact. using the depression, anxiety and stress scale (dass- ), . % had moderate to severe anxiety symptoms, . % had moderate to severe depressive symptoms, and . % had moderate to severe stress levels. notably, specific physical symptoms such as myalgia, dizziness, coryza, and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression [ •] . another similar study in the general population on generalized anxiety disorder (gad) symptoms, depressive symptoms, and sleep quality revealed similar findings. results showed that the overall prevalence of anxiety symptoms (using generalized anxiety disorder -item score > ) was . %, depressive symptoms . %, and poor sleep quality . %. of note, they also found that hcws were more likely to have poor sleep quality than the general population [ results from previous pandemics were limited and did not explore the effect of quarantine on children and families. however, initial data from the covid- pandemic has shown a detrimental effect of quarantine on children. a survey of primary school students (grades - ) in the hubei province of china during lockdown measures found that . % reported depressive symptoms and . % reported anxiety [ •] . in shanghai, parents of children with attention-deficit/hyperactivity disorder (adhd) aged - reported that their behaviors were significantly worse during lockdown [ •]. among chinese students aged - , prevalence of depressive and anxiety symptoms were . % and . %, respectively, with risk factors including female gender, higher grade level, and lower self-assessed knowledge of covid- [ • ]. published data regarding mental health sequelae from recent pre-covid- pandemics is limited. most studies have used broad-sweeping inventories of distress and psychological symptoms instead of specific diagnostic screening instruments. very few prospective clinical trials appear to have been published, and the few reasonably well-constructed retrospective trials had relatively small study populations. reported outcomes included vague, qualitative entities such as stress, anxiety, panic, worry, exhaustion, emotional disturbance, ptsd symptoms, depressive symptoms, poor sleep quality, increased alcohol use, and behavior problems. additionally, the fast-moving nature of the pandemic, combined with the challenge of getting behavioral health protocols rapidly approved by institutional review boards, has likely contributed to the scarcity of covid- -related outcome data. given these limitations, we found it difficult to predict with certainty which types of mental health problems are likely to result from covid- . however, several general trends and observations are worth noting and may provide some preliminary assistance to medical planners responsible for anticipating the psychological sequelae of covid- . the data above is consistent with what we already know about the mental health impacts after a disaster: a significant number of people will experience increased stress during the incident, but the majority will not have lasting psychological sequelae. while this is an important perspective, there are also several differences between past pandemics and the current situation. covid- appears to be more similar to influenza outbreaks than to previous coronavirus infections, with respect to high infectivity, low fatality rates, and a high percentage of asymptomatic infections [ ] . from a mental health standpoint, these conditions have the potential to lead to significant anxiety over whether one has the virus and could be unknowingly passing it on to their loved ones. compared with other recent pandemics, covid- has considerably more cases with global spread, causing significant impact on daily lives. no other outbreak in recent history has caused such devastating economic distress or the mass closure of businesses. furthermore, the sheer number of patients infected and hcws exposed could cause significant strain on the mental healthcare system, even if the majority of people affected do well in the long term. with cases continuing to surface, there is still a great degree of uncertainty regarding the final impact this pandemic will have, including when a vaccine will be developed and how long social distancing precautions will need to continue. these additional factors may lead to more severe psychosocial distress and unanticipated psychiatric disease than has been observed in previous pandemics. data on the effects of the covid- pandemic on children and families are currently limited. however, experts anticipate that all families, regardless of whether family members include patients or hcws, will be affected due to disruption of the family structure by closures of schools, financial uncertainty, and possible unemployment [ ] . while mental health professionals attempt to forecast and implement effective treatment for the most vulnerable populations, much is unknown about the long-term mental health effects of largescale disease outbreaks on children, adolescents, and families. evolving data suggests that the greatest risks among these populations will include increased anxiety regarding school and work closures, decreased social and community networks, increased pressure on parents to work from home while providing supervision and distance learning, violence when locked in with abusive family members, and unemployment potentially leading to loss of essentials, starvation, and homelessness. with numerous predictions and peer-reviewed data emerging about the mental health consequences of covid- , one may conclude that healthcare systems and providers must simply anticipate increased demand for all types of psychiatric conditions. however, the information presented above does suggest certain trends that may inform planning more specifically. first and foremost, several studies noted that individuals' levels of anxiety were indirectly correlated with the degree of communication they received about the virus. mental health providers, and particularly those trained in the military as command consultants, are uniquely suited to prepare evidence-based communication tools for patients and fellow clinicians, as well as for community leaders hoping to minimize social panic. such tools should cover what is known about transmission of the virus, for example, how individuals are likely to be infected, what mitigation strategies are most effective, how they should be employed, who is at highest risk for the worst outcomes, who is at greatest risk for psychiatric sequelae, and how mental health may be optimized among affected individuals. communication also includes providing subject matter expertise to medical and community leaders. mental health providers should not wait to be asked; they should prepare succinct talking points and intermittently remind public officials and other senior leaders of the most prominent fears fueling anxiety in the community. additionally, it is important to offer practical and viable suggestions or solutions; providers who present leaders with concerns without solutions will rapidly lose favor with the same individuals they are hoping to influence. second, the aforementioned studies found excessive worry and distress about various covid-related issues. although there are scores of evidence-based interventions likely to be useful for anxiety and depression, two widely available strategies can address both problems effectively, when used in those identified to be appropriate for treatment: cognitive behavioral therapy (cbt) and antidepressant medications [ ] [ ] [ ] . third, post-traumatic stress symptoms were surprisingly prevalent across pandemics and among numerous demographic groups, suggesting that interventions proven to be effective for ptsd may be a worthy investment of training dollars and clinical resources. traditional, - session manualized treatments using prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing are likely to be effective [ ] [ ] [ ] . however, recent data suggests that interpersonal therapy, written exposure therapy (wet), strategically dosed propranolol, and mantram repetition may be equally effective and easier to facilitate via telehealth [ ] [ ] [ ] [ ] . generally, individual psychotherapy has been shown to be more effective than group-based interventions or medications alone for ptsd [ ] . however, in areas where resources are limited, group-based interventions in which cohorts with similar backgrounds can process their experiences together (i.e., front-line workers, covid- survivors, unemployed individuals) may be clinically beneficial. treating ptsd may also improve insomnia, a symptom of ptsd, that was noted to be prevalent in several of the pandemic-related studies cited above. fourth, most responses seen in children during covid- and previous pandemics tend to fall into two major categories-anxiety and restless/disruptive behavior. since the latter can be a manifestation of the former, planning ways to address anxiety in children is likely to be the best investment of limited clinical resources. researchers at the yale university recently demonstrated that coaching for parents in how to manage their anxious children can be as effective as individual cbt conducted with the children themselves [ ] . children may also benefit from individual-or groupbased therapy, especially if they are focused on practical matters, such as how to be good siblings, how to prevent the spread of covid- , and ways to burn off energy that accumulates during isolation. fifth, although entrepreneurs are rapidly adapting their business models to accommodate infection control measures, sustained high unemployment rates and economic depression appear unavoidable. historically, financial crises heighten emotional despair and increase rates of suicide [ , ] . the extent to which covid- will be associated with these impacts is unknown, although some models predict that up to % of jobs lost during covid will be permanent [ ] . planning for the psychological needs of individuals facing economic devastation is challenging. not only is there stigma in acknowledging one's financial situation, but the very nature of the problem itself creates a barrier to accessing treatment. the best planning for these outcomes will likely involve nontraditional approaches, such as partnering with community leaders to educate them about the psychological impact of unemployment, getting the word out about available food and shelter, and creating per diem jobs and apprenticeship opportunities. free support groups and training seminars on topics such as unemployment rights, resume building, and civil service opportunities are likely to make a greater impact than psychotherapy in this population. finally, covid- has created many additional psychological problems not widely emphasized among available data, including domestic violence and child abuse. while physical distancing at home is necessary to prevent the spread of disease, social isolation is also a major tactic used by perpetrators of domestic abuse. strict requirements to maintain isolation may allow perpetrators to gain control by generating guilt in their victims [ ] . isolation from friends, family, and employment plays a role as fewer contacts means fewer people to recognize abuse and provide assistance. typically, % of reports to child protective services come from educators [ ] . because schools and other childcare facilities are closed, families at risk are not likely getting the resources or referrals they need. both substance misuse and domestic abuse are likely to be underreported, yet they are of critical significance. additionally, many minority populations and lowerincome front-line workers are at risk for greater exposure to covid- , greater risk of developing serious medical sequelae, lower likelihood of insurance coverage, and increased institutional bias that may negatively impact their course of treatment [ ] . providers and medical staff who regularly care for these populations should be reminded of the risks incurred by these vulnerable populations and utilized to train their medical peers on how to screen at-risk patients, as well as how to optimize patient access to treatment resources and shelters. there have also been many accounts of discriminatory behaviors against asian americans and pacific islanders (aapi) since the covid- outbreak [ , ] . it is now widely known that in general, the experience of racial discrimination is a determinant of poor mental health [ ] [ ] [ ] . thus, it is important for providers to be aware of these experiences and anticipate increases in the secondary effects of discrimination, such as psychological trauma, anxiety, and depression in these populations. lastly, bereavement will unquestionably be a significant consequence of covid- , yet available literature from covid- and past pandemics is remarkably void of data on grief and bereavement [ ] . the covid- pandemic has changed the landscape of behavioral health dramatically. expanded telehealth capabilities have increased our ability to reach those suffering and provide better patient-centered care, yet these new care delivery systems are not ubiquitously available. furthermore, testing these capabilities may be a trial by fire if predictions about a looming mental health crisis prove accurate. it is therefore important to focus planning efforts on interventions likely to have the greatest impact. evidence-based treatments for ptsd, anxiety, and depression, particularly those more easily delivered using virtual platforms, should become the standard post-covid toolkit for behavioral health clinicians. groupbased interventions will also be critical, particularly for parents, children, and cohorts of similarly impacted individuals, to decrease isolation, normalize experiences, and promote emotional validation. simply being able to direct suffering individuals to support groups and self-help/educational resources may be as impactful as traditional behavioral health interventions. such community-based support is widely used in the american military and is consistent with the doctrinal principles of military disaster response [ ] . this analysis was based on peer-reviewed and non-peer-reviewed scholarly reports, many of which were of limited quality and frequently retrospective in nature. additionally, much of the covid- data is still in pre-print form as of this writing. our rapid review of the existing literature was intended to provide military and civilian mental health planners with timely, actionable data to help guide their decisions regarding staff training and resource allocation. however, we acknowledge that our rapid method of review may have excluded some informative publications that would have been identified if we had used a full prisma systematic review. future research on planning and response to post-pandemic mental health demands should be based on prospective, randomized, controlled, peerreviewed data whenever possible. it is our hope that research will continue into the ongoing psychological impact of covid- . disclaimer the views expressed in this manuscript are those of the author and 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meta-analysis the social determinants of mental health: psychiatrists' roles in addressing discrimination and food insecurity. focus (am psychiatr publ) this article nicely describes the social determinants of mental health, including discrimination and food insecurity cumulative effect of racial discrimination on the mental health of ethnic minorities in the united kingdom supporting adults bereaved through covid- : a rapid review of the impact of previous pandemics on grief and bereavement department of the army. the u.s. army/marine corps counterinsurgency field manual: u.s. army field manual no. - : marine corps warfighting publication no. - publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -pl hyzwp authors: carbone, stephen r. title: flattening the mental ill-health curve: the importance of primary prevention in managing the mental health impacts of covid date: - - journal: ment health prev doi: . /j.mhp. . sha: doc_id: cord_uid: pl hyzwp the covid pandemic is one the biggest challenges the global community has faced. the threat of the virus coupled with the impacts of the social and economic shut-down measures required to slow its spread, already appear to be impacting on people's mental health and wellbeing. over the weeks, months and years ahead it is likely that many countries will experience a ‘wave’ of covid related mental disorders as a result of an increase in risk factors linked to the pandemic such as social isolation; child-maltreatment; intimate partner violence; unemployment; housing and income stress; workplace trauma; and grief and loss. the ‘two-pronged’ approach used to deal with covid , provides an excellent blueprint for managing its mental health impacts as well. nations must focus on preventing the occurrence of new cases of mental disorders as well as strengthening their mental healthcare response to support people who become mentally unwell. a focus on primary prevention is particularly important to ‘flatten the curve’ and avoid a surge in incidence of mental disorders stemming from the covid pandemic. many evidence-based interventions designed to prevent common disorders are already available and should be scaled-up. these interventions include parenting programs, social and emotional learning programs, self-care strategies, and workplace mental wellbeing programs, among others. flattening the mental ill-health curve: the importance of primary prevention in managing the mental health impacts of covid title flattening the mental ill-health curve: the importance of primary prevention in managing the mental health impacts of covid author names and affiliations. the coronavirus disease (covid ) pandemic is one the biggest challenges the global community has faced. across the world, scores of countries have imposed strict physical distancing and socioeconomic lock-down measures to prevent the spread of the sars-cov- virus. the sudden and dramatic changes to people's lives and livelihoods are creating high levels of stress among people across the world. much of this stress is a normal and hopefully temporary reaction to the new and uncertain nature of the situation and the social and economic disruption it has created. however, there are worrying signs that stress levels are becoming problematic and causing some in the community to experience levels of psychological distress suggestive of emerging anxiety and mood disorders (scott & kinsella, ) . there are also concerns people already living with a mental disorder may experience a worsening of their condition (yao, chen, & xu, ) . it is likely that many countries will experience a 'wave' of covid related mental disorders over the weeks, months and years ahead (montemurro, ; moukaddam & shah, ; shigemura, ursano, morganstein, kurosawa, & benedek, ) (see figure ). the 'two-pronged' approach used to deal with the virus, also provides an excellent blueprint for managing its mental health impacts. nations should focus on preventing the occurrence of new cases of mental disorders as well as strengthening their mental healthcare response to support people who do become mentally unwell. in many countries work on the latter has already started, with mental healthcare service delivery redesigned to align with physical distancing restrictions and efforts made to boost capacity. in australia, the federal government has increased the availability of telephone help-lines, clinician supported and self-directed online treatment programs, and telehealth mental health consultations (departmentofhealth, ). however, while mental healthcare system strengthening measures are vital, on their own they will not 'flatten the mental health curve'. a focus on primary prevention is also needed to avoid a surge in incidence of mental disorders stemming from the covid pandemic. what can we do to prevent covid- related mental ill-health? there is nowadays good evidence to show that mental disorders are not inevitable and many common conditions can be prevented from occurring (arango et al., ; mendelson & eaton, ) . wide-scale use of evidence-based preventive interventions that address the risk factors that are escalating due to the pandemic, including social isolation; child-maltreatment; intimate partner violence; unemployment; financial and housing stress; work-related trauma; and grief and loss will be needed. the mental wellbeing of children, young people and their parents and carers, is a priority. practical and emotional support, and assistance with material basics for parents experiencing socioeconomic disadvantage, can help to reduce the stress many parents are feeling. existing evidence-based parenting programs focused on the prevention of conduct disorders, depression, and anxiety, particularly those available online, can assist parents to manage the dramatic changes in family life wrought by covid . parenting programs targeted to the prevention of childhood maltreatment and other adverse childhood experiences are also needed to counteract the increase in these particular risk factors that physical distancing and quarantine measures have created. skills-building programs that enable children and young people to acquire the social and emotional skills that contribute to resilience, mental wellbeing, and a reduced risk of mental disorders also need to be scaled-up. many evidence-based programs designed for school-based delivery already exist but are often poorly implemented due to the lack of time, resourcing and professional development offered to support educators to deliver these programs. since many schools are closed it may be possible to utilise this opportunity to offer educators intensive training in these prevention-focused programs so they can implement them effectively when students return to the classroom. adapting such programs to online delivery should also be considered, so children, young people and their parents and carers can access them independently. adults too need attention. a public awareness campaign encouraging people to look after their mental health as they would look after their physical health would help raise awareness and encourage action. self-care strategies drawn from health, clinical and positive psychology that are known to enhance mental wellbeing and reduce the odds of mental ill-health could be promoted through such campaigns as well as through online learning programs for adults. these strategies need to be widely promoted with messaging nuanced over time to align with the evolving nature of the stressors that people are experiencing. workplace mental wellbeing initiatives tailored to tackling the new stressors and changes in work practices caused by covid are needed across all workforces. those on the frontline of pandemic response efforts, such as healthcare workers, should be a distinct target for prevention programs given the work-related trauma many have experienced. tackling loneliness is also vital and the elderly are a key focus. many may have already been experiencing loneliness pre-covid and physical distancing restrictions may have exacerbated these feelings further. moreover, in the absence of a vaccine or effective treatment for covid , the public may still be encouraged to minimise social contact with older people even as physical distancing restrictions ease, putting older persons at risk of protracted periods of isolation and loneliness. attention should also be given to public policies to help people cope through the current upheaval as well as its social and economic aftermath. the covid pandemic has highlighted the importance of social policies that ensure people have equitable access to the social determinants of health and mental health, like good-quality education, a living wage, stable housing, and affordable access to health and mental healthcare. in some countries crucial social policies have already been put in place. in australia, federal government funded income support has been increased for the elderly and the unemployed. businesses that have experienced a drop in income are entitled to subsidies to help them retain and pay their workers. banks are able to adjust loan repayments and landlords are being supported to reduce rents for individuals and businesses experiencing income stress. these policies must be kept in place for as long as possible. data to guide action is essential. covid has shown the importance of reliable, real-time information to enable tailoring of response measures. population-level data on risk and protective factor exposure and levels of mental wellbeing and psychological distress would be invaluable. as countries slowly control the spread of the sars-cov- virus a new challenge for governments will be how to avert a potential mental health crisis as individuals and communities experience the social and economic aftershocks of the pandemic. strengthening the mental healthcare system is important, but on its own it will not address this problem. primary prevention must be a parallel part of the solution. a number of evidence-based approaches to primary prevention already exist and can be scaled-up immediately, while we continue to support research to find new and more effective approaches. preventive strategies for mental health. the lancet fact sheet covid- national health plan -supporting the mental health of australians through the coronavirus pandemic recent advances in the prevention of mental disorders. social psychiatry and psychiatric epidemiology the emotional impact of covid- : from medical staff to common people psychiatrists beware! the impact of covid- and pandemics on mental health mental health and covid- -how the coronavirus is affecting our way of life public responses to the novel coronavirus ( -ncov) in japan: mental health consequences and target populations patients with mental health disorders in the covid- epidemic key: cord- -bxcsa h authors: gordon, joshua a.; borja, susan e. title: the covid- pandemic: setting the mental health research agenda date: - - journal: biol psychiatry doi: . /j.biopsych. . . sha: doc_id: cord_uid: bxcsa h nan conjoint threats to public mental health. these threats include fear of the potential for infection by the virus itself; social isolation and alterations in health-related behaviors caused by mitigation measures aimed at reducing viral transmission; financial insecurity secondary to the economic consequences of the pandemic; and disruption of the healthcare system. simply put, this is a disaster with consequences beyond the immediate health impact of the virus. while the covid- pandemic is in many ways unique, unfortunately, disasters and large-scale emergency events happen somewhere in the world each day and typically, there is more than one disaster in the united states nearly every week . research from past large-scale traumas can inform our knowledge of mental health effects, risk and resilience factors, and effective services and interventions, enabling us to anticipate the likely mental health impacts of the current pandemic. this prior research also lays bare what we do not know and sets the research agenda for the national institute of mental health's response to covid- . individuals exposed to a disaster experience a wide range of reactions. in a comprehensive literature review encompassing study samples from different events comprising over , individuals, norris et al. ( ) described the worry, fear, distress, somatic complaints, and sleep difficulty that are common for many people early after exposures to traumatic experiences. of the disasters studied, relatively few samples ( %) showed minimal or highly transient impairment; half of the samples showed moderate impairment; and, the rest showed clinically significant distress ( %) or severe symptoms indicative of a diagnosable psychological disorder ( %). for most individuals exposed to disasters, the initial experience of mild and even significant symptoms tend to improve with time, but a significant minority (~ %) may have longer term or chronic experiences with mental illness . individuals may be at higher risk of chronicity if they have few social supports, a history of prior trauma, a history of mental illness, were exposed directly to deaths or injuries, had severe acute reactions to the disaster, or are experiencing ongoing stressors (including occupational or financial strain) . frontline healthcare workers treating the sick and dying may be at higher risk for experiencing psychiatric morbidity, at least acutely . as with routine stressful and traumatic events, there is no single variable that determines individual outcomes; the additive total of risk and resilience factors will determine how each person will respond . meeting immediate needs may help mitigate some long-term impacts of trauma on mental health. practicing healthy coping strategies (noting accomplishments, setting reasonable expectations, talking, exercising) and avoiding substance abuse also tend to help with recovery. not everyone recovers without intervention. for those who experience new or worsening illness, treatment can help . indeed, promoting mental health recovery with evidence-based screening, assessment, treatment, and care coordination, while expensive, is likely to be cost-effective in the long term. of particular concern with the covid- pandemic are the potential effects of mitigation strategies on mental health. we need to understand the risks and benefits of public health policies and guidelines, and support approaches to increase resilience to their adverse mental health effects. again, past results help inform our expectations. the first severe acute respiratory syndrome (sars) outbreak in - was ultimately contained globally through widespread quarantine measures. during these efforts, longer durations of quarantine were associated with increased reports of distress, as well as symptoms of posttraumatic stress and depression . add to these effects the potential negative impact of the economic distress that has accompanied the widespread shutdowns during covid- , and the consequences for at-risk individuals may be particularly severe. here, a modern, data-focused research strategy has the potential to yield insights based on geographic and jurisdictional variance in recommended mitigation approaches and the public's adherence to them. public and commercial health and administrative databases can be combined with ongoing cohort studies to understand how public health directives, compliance with mitigation measures, and economic sequalae interact with risk and protective factors to alter mental health trajectories. such studies will not only inform our response to covid- , they will also improve preparations for and responses to future pandemics. in the united states, the mental health care system is unable to meet the needs of people with mental illnesses in the best of times . delivering adequate care during disasters and other large-scale traumas is especially challenging. consider the example of hurricane katrina: months after the storm, fewer than % of people who developed mood or anxiety disorders received any care; of those who did, % had discontinued treatment. undertreatment was associated with a number of demographic factors, including age, marital status, racial and ethnic minority status, insurance status, and income. this is the crisis we face. the anticipated surge in demand for mental health care could quickly overwhelm capacity, particularly in specialties (such as child psychiatry) or locales (such as rural areas) where an existing shortage of providers is known. gaps in and barriers to care for many vulnerable populations (including those with serious mental illness, in under-resourced communities, in prison, or who are homeless) are known challenges with unknown solutions. research aimed at discovering solutions to these challenges needs to be prioritized. this research should be focused on leveraging the available mental health workforce, enabling practical, scalable, and sustainable mental health screening and triage, and providing interventions at scale. interventions for treatment of acute illness and prevention of chronicity need to be tested across the lifespan and along a continuum of intensity. technological approaches, including digital and telehealth, will likely be crucial, but additional approaches must also be considered to ensure that interventions can reach those with limited access or familiarity. research to understand and improve engagement and continuity of care, including approaches to facilitate (re)connection to care for persons with serious mental disorders who experience disruption in services, is needed. finally, vulnerable populations, including those with serious mental illness or health disparities, are less likely to engage in mental health care, highlighting the need for innovative approaches. this is the research agenda we are pursuing at nimh in response to the covid- pandemic. we seek to understand the unique aspects of the covid- pandemic, particularly with regard to interactions between risk and resilience factors and mitigation efforts. but even more crucially, we seek to understand how to best utilize current treatments, imperfect as they are, in order to optimize a ready armamentarium that has proven helpful; research is now needed to inform the next steps that will make these treatments widely accessible across cultural, racial, economic, and technological divides. in this way, the mental health research community, working in concert with clinicians and policy makers, can reduce the adverse impacts of the covid- pandemic while developing the evidence base necessary to meet the demands of future disasters. disclosure statement: the authors report no biomedical financial interests or potential conflicts of interest. long-term psychological and occupational effects of providing hospital healthcare during sars outbreak. emerging infectious diseases weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities postdisaster psychological intervention since / k promoting mental health recovery after hurricanes katrina and rita arch gen psychiatry sars control and psychological effects of quarantine twelve-month use of mental health services in the united states: results from the national comorbidity survey replication rc disruption of existing mental health treatments and failure to initiate new treatment after hurricane katrina key: cord- -rtm dn authors: o’connor, karen; wrigley, margo; jennings, rhona; hill, michele; niazi, amir title: mental health impacts of covid- in ireland and the need for a secondary care mental health service response date: - - journal: irish journal of psychological medicine doi: . /ipm. . sha: doc_id: cord_uid: rtm dn the covid- pandemic is a global health emergency, the scale, speed and nature of which is beyond anything most of us have experienced in our lifetimes. the mental health burden associated with this pandemic is also likely to surpass anything we have previously experienced. in this editorial, we seek to anticipate the nature of this additional mental health burden and make recommendations on how to mitigate against and prepare for this significant increase in mental health service demand. the psychosocial footprint associated with a major emergency is typically larger than the medical footprint. this is because the psychosocial impact extends beyond those who suffer direct medical injury to first responders, healthcare professionals delivering care to the ill, family, friends and the wider community (nato joint medical committee, ; shultz et al. ; health service executive, ) . the covid- pandemic is a global health emergency, the scale, speed and nature of which is beyond anything most of us, service users, healthcare staff or the general public have experienced in our lifetimes. the mental health burden associated with this pandemic is also likely to surpass anything we have previously experienced. therefore, it is essential for mental health services in ireland to anticipate the nature of this need and plan a coordinated response to address it (see fig. ). to better define and plan for the mental health impact of this pandemic, an expert working group was formed in the office of the national clinical advisor and group lead for mental health in the health service executive in ireland. this expert working group was made of up of the authors and involved additional consultation with mental health experts from across the mental health specialties including general adult, child and adolescent, intellectual disabilities and psychiatry of later life. the likely timeline and nature of the various waves of health needs that will arise because of the covid- pandemic are illustrated in fig. . while the irish health service must prepare in the first instance for the first pandemic wave, we also need to plan and mitigate against the impact of the subsequent three waves of healthcare need (see fig. ). the second wave will arise because people who are in acute need of health care, for example, myocardial infarction or first-episode psychosis forestall accessing care because of fears of covid- infection or because in isolation their symptoms are not recognised. this could result in a significant increase in acute non-covid morbidity and mortality. the third wave will arise from the longer-term impact on people with established health problems, for example, diabetes, eating disorder or schizophrenia not accessing routine care due to health service reconfiguration, service reduction or fears of infection. this will result in people who were stable, deteriorating over time. for example, an individual is unable to attend the diabetic clinic because it is cancelled or delayed, resulting in poorer glycaemic control. a mental health example might be where an individual with an established psychotic illness is unable to attend their weekly therapeutic group, loses their job, has their routine outpatient review rescheduled and experiences increased loneliness, isolation and a relapse of psychotic symptoms. the largest and longest fourth wave of healthcare need will encompass the psychosocial and mental health burden associated with this pandemic. this final tsunami will not peak until sometime afterwards (months) and will sustain for months to years after the covid- pandemic itself. a proportion of this psychosocial and mental health need can be met at a community and primary care level in the first instance. however, a significant proportion will require specialist intervention from secondary care mental health services. in this editorial, we seek to describe and make recommendations on how to mitigate against and prepare for this increase in mental health service demand. however, it is important to note that any plan developed in the context of this pandemic will require review and revision as further evidence becomes available. features particular to this pandemic that will result in an increased mental health burden in the medium to longer term there are several features particular to the covid- emergency that are likely to amplify and prolong both the psychosocial and the mental health burden associated with this pandemic. these features include the morbidity and mortality associated with covid- , the relentless media coverage, the social distancing measures, the altered pathways to access care, the changes to the care that is available, the suspension of development plans in mental health services and the economic impact on all populations in society. table describes these features in more detail. the social distancing measures do not impact on all equally. those with the fewest social and economic resources to alleviate the effects of social restrictions will be impacted the most (morgan & rose, ) . this includes those living in deprived areas, with insecure and or low-income jobs, insecure housing, singleparent households or abusive relationships. it also acutely affects those with existing mental health problems, whose symptoms may worsen when access to social connections and healthcare support is restricted. the economic impact of the pandemic will further exacerbate and prolong this. the national clinical programmes (ncps) in mental health were developed in conjunction with the college of psychiatrists of ireland and are nationally led programmes seeking to improve access, quality and cost of mental health care. there are also two nationally led initiatives to support the development of perinatal mental health services and mental health services for people with an intellectual disability. these programmes were developed to address areas of known service deficit, or indeed where there was an absence of service. the continued implementation and investment in these ncps need to be enhanced during covid- . groups who will be particularly vulnerable to the emergence of new mental health difficulties requiring secondary care interventions this pandemic will be associated with an increase in people presenting for the very first time with significant mental health difficulties. several groups are likely to be particularly vulnerable. some people who have had a severe episode of covid- illness may experience high levels of psychiatric family members who have lost a loved one, who were separated from loved ones who were very ill and or died may be vulnerable to developing psychiatric relentless media coverage difficult to cope with anxiety, fear and anticipation of the pandemic. difficulty sleeping, eating, taking a break from coverage and impact. social distancing measures greater impact on vulnerable groups, for example, those in poverty, insecure housing/work, single-parent families, abusive relationships, direct provision and people with mental illness who will have less social and professional support. secondary economic crisis well-established association with higher rates of mental illness, suicide and substance use disorders reduced non-covid- health service utilization reluctance to attend for acute care due to fears of covid- infection resulting in delays in effective treatment and increase in crisis presentations reduced availability/altered access to mental health services reconfiguration of services and redeployment of staff results in reduced access to care retraction of the national clinical programmes • self-harm • inability to meet the anticipated increase in self-harm presentations • associated with increased morbidity, mortality and increased burden on community mental health teams • early intervention for psychosis failure to implement national roll out in line with model of care resulting in: • increase in duration of untreated psychosis and an associated worsening of prognosis. • failure to deliver evidence-based interventions resulting in increased relapse, increased crisis presentations, increased hospital admissions, worse health outcomes. • eating disorders failure to implement national roll out in line with model of care resulting in: • delays in accessing service • increased reliance on costly hospital admissions and expensive out of country placements. • failure to deliver evidence-based interventions resulting in poorer prognosis, increased crisis care and increased reliance on hospital admissions • attention deficit hyperactivity disorder in adults failure to implement national roll out in line with model of care resulting in: • little to no access to assessment and treatment in adults mental health impacts of covid- in ireland illness. it was estimated that % of family members of sars patients experienced psychological problems (mainly depressive symptoms) and stigmatisation (tsang et al. ) . in the sars research, healthcare professionals were found to be particularly vulnerable to psychiatric morbidity during and after the acute pandemic wave (wu et al. ). a study of healthcare workers in beijing, china, years after the sars epidemic found that % continued to experience high levels of posttraumatic stress (wu et al. ). those with fewer social and economic resources as described previously, those living in difficult or unstable personal/housing/employment circumstances will likely experience greater mental health impact and burden. leading theories of suicide emphasise the critical role that social connections play in suicide prevention (reger et al. ) . individuals experiencing suicidal ideation may lack connections to other people and often disconnect from others as suicide risk rises. social distancing itself may be a significant risk factor for an increase in self-harm and suicide for some people. the economic impact of the pandemic is becoming increasingly apparent, with unemployment rates rising dramatically, which is an established risk factor for mental ill health across the lifespan. this is likely to further compound this vulnerability and increase these risks (corcoran et al. ) . while these issues effect all age groups, there are subgroups that are likely to be more vulnerable. older people who are at higher risk of developing a severe form of covid- , particularly those who have been asked to cocoon, may be experiencing more anxiety and more isolation. disrupted routines and reduced activity levels may undermine independence, exacerbate frailty and poor health outcomes in this population. for those with dementia living at home, an incomprehensible disruption to the person's usual routine can lead to anxiety, agitation and sleep disturbance. not being able to leave the house may cause an extreme reaction towards well-meaning family carers causing distress to all. in nursing homes, family and friends no longer being able to visit will distress residents. this is particularly true of those who are cognitively intact who may be equally worried about their families catching covid- . this is especially the case if they are aware of the deaths of fellow residents from covid- . young people (aged - ) are already the highest risk age for developing a mental disorder, and third-level students report even higher levels of distress than their age-matched peers (karwig et al. ; union of students of ireland, ). a combination of accelerated brain development and the developmental task of transition to adult life and learning are some of the explanatory factors (duffy et al. ) . these preexisting vulnerabilities are not removed by the pandemic, and fears and uncertainty about future employment and economic stability are likely to be exacerbated by the financial impact on all of society. prior to covid, the my world survey in , a self-report survey, showed that the already high rates of depression, anxiety and self-harm in young people reported in my world survey ( ) had risen even further (dooley, ) . irish youths have the fourth highest suicide rate in europe (unicef, ). covid is likely to impact more on the mental rather than the physical health of this group. with austerity measures, separation from peers and forced quarantine with family (who in some cases may not be a safe space) are being challenges for young people. many have had their school and college lives disrupted, their state or college exams altered or brought forward. their already uncertain futures looking even less clear. there are of course exceptions, for example, those with social anxiety or who were experiencing bullying. however, those subgroups will likely need even further support to re-engage with society after social restrictions are lifted. individuals with intellectual disability may struggle to understand the requirements of social restrictions and may find the disruption to their routines and reduced access to usual social supports, for example, work, and day programmes as very distressing. people with autism, within the learning disability population, may be particularly impacted, as changes in routine can be incredibly challenging for them. rates of mental ill health within the learning disability population already exceed those in the general population and the pandemic may exacerbate this further (hughes-mccormack et al. ). some individuals with intellectual disability live in congregated settings. such settings may be more vulnerable to covid- infection outbreak, and this may result in increased exposure to the morbidity and mortality and, therefore, opportunity to witness the impact on others of this pandemic. the covid- pandemic is associated with a combination of factors such as worry about infection, direct effects of the virus on the foetus or on an infant, visitor restrictions, social isolation, financial strain, domestic violence and grief due to loss of family members that are likely to increase the prevalence of mental health difficulties in women during the perinatal period. the impact of no visitors in the post-partum period, or of no partner being permitted during caesarean sections during covid- , may be very anxiety provoking for some. reduced social support in the post-partum period, increased economic pressure and increased risk of domestic violence are additional potential stressors in this population. as mentioned previously, there are two nationally led clinical programmes in place to support the development of mental health services for people with an intellectual disability and the perinatal mental health services. it is critical that in the context of covid- , the development of these services is fast-tracked. people with established mental illness are likely to be particularly vulnerable to relapse, exacerbation of symptoms and impaired functioning in the context of the covid- pandemic (see table ). furthermore, people with established mental illness also have a lower life expectancy and poorer physical health outcomes compared to people in the general population (rodgers et al. ) . risk factors associated with poorer outcomes in covid- infection include smoking, diabetes, cardiovascular disease and obesity. these risk factors are all more prevalent in people with established mental illness. as such, people with established mental illness may be at risk of poorer mental health and physical outcomes in this pandemic (cullen et al. ) . funding of mental health services in ireland has remained consistently low,~ % of the overall health budget (compared to % in new zealand and united kingdom) (college of psychiatrists of ireland, ). ireland has the third lowest number of psychiatric beds in europe (eurostat, ). the staffing recommendations for mental health teams set out in a vision for change have never been achieved. the latest data from the health service executive in december put the staffing levels of child and adolescent mental health teams, psychiatry for older persons teams and psychiatry for people with an intellectual disability, as a percentage of avfc recommendations at %, % and %, respectively. mental health services are underfunded across the board; however, there is a societal recognition of the mental health needs of young people, and yet they struggle the most to access secondary care. this is perhaps a result of the traditional adult-paediatric split, which does not match the epidemiology. it may also be a consequence of underfunded services being unable to respond to young people until conditions are much more entrenched or repeated crises have occurred. like the scenario faced by intensive care units at the start of this covid pandemic, in mental health, we are starting at a low base and facing into a tsunami of mental health need. similar to the approach taken in the acute hospitals, we need urgent investment, building of capacity and innovation to ensure that mental health services are not overwhelmed and are able to respond to service users in a timely manner. ring fence a specific budget to allow mental health services to build capacity, adapt and innovate. in line with slaintecare, we need to have the right care, available at the right time, in the right place (houses of the oireachtas committee on the future of healthcare, ). redeployment of mental health staff during the acute pandemic should be minimised and only occur in very extreme and time-limited circumstances. a ring-fenced covid- research budget, within a collaborative interagency framework, should also be introduced. services will need to adapt and transform. however, it is critical that evolving approaches are evaluated to ensure feasibility/ acceptability and that they are associated with good health outcomes for service users and their families. youth mental health services rest in the domain of primary care counselling services in ireland, with no representation from psychiatry, perhaps reflecting a misguided belief in the general population, and at government level, that mental illness can always be prevented. these services are ill equipped to manage the full range of presentations that seek help. without funded vertical integration pathways and ring-fenced funding to secondary care, there is a risk that already limited funding in amhs and camhs will be channelled away from where it is most needed. even in countries with significantly more enhanced primary care youth mental health services, there is a recognition that % of young people who present (headspace australia) have needs that are in excess of what can be managed there (rickwood et al. ) . the youth mental health taskforce recommended appointment of national and local ymh leads, a focus on improving mental health services in third-level institutions, and upscaling of digital interventions all of which now need to be implemented (national youth mental health taskforce, ) . mental health impacts of covid- in ireland increased risk of relapse of anxiety disorder symptoms including panic attacks, agoraphobia, health-related anxiety symptoms obsessive-compulsive disorderfear of contamination and increased compulsive behaviours, for example, handwashing, checking, routines. increased risk of trauma relating to the experience of covid- illness or witnessing impact of illness on service user, friend and family. increased social isolation and loneliness insomnia, altered appetite, reduced exercise, disrupted routine. personal experience of covid- in self/family or friends. rates of isolation and loneliness are higher in this population at baseline. increased difficulty accessing care due to altered pathways and increased isolation from family/friends. those with negative symptoms will be particularly affected by the change in routines, reduced interaction and social distancing measures. viral infection appears to be a general risk factor for psychotic disorders, and coronavirus infection may also be a specific risk factor, conferring acute and long-term risk for psychosis (cowan, ) . trauma and social marginalisation are risk factors associated with longer term increased risk of psychosis (radua et al. ) . relapse of psychotic symptoms, for example, hallucinations, delusions. increased duration of untreated psychosis resulting in poorer prognosis. further impairment of social and occupational functioning, which will be difficult to re-establish after covid- . difficulty/fear of accessing evidence-based interventions, for example, psychological interventions, family interventions, individual placement support, physical health interventions. impact of telephone versus face-to-face assessments, therapeutic interventions. potentially increased longer-term risk of psychosis in the population. the rapid upscaling of the information technology infrastructure has been a very positive consequence of covid- . however, access to smart phones, laptops and high-quality broadband is an issue in many areas. this needs to be addressed as a priority. we also need to adapt and develop digital health interventions, for example, psychological interventions, family interventions, peer to peer supports, physical health interventions to augment services capacity to deliver evidence based care in the context of covid- (alvarez-jimenez et al. ) . the need for electronic records and data collection systems that monitor patient outcomes should also be developed in tandem with telemedicine. a specific budget to support and protect the implementation of the ncps during covid- should be identified. adequate resourcing of these programmes will ensure that areas of the mental health service that have already been identified as severely lacking will be able to meet demand. now is not the time to fall backwards in the delivery of high quality, accessible care. rather we need to accelerate service transformation and to build and strengthen capacity in our mental health services. because of covid- , secondary care mental health services are facing a huge escalation of mental health need. it is emerging now, will peak in a few months' time and will last for many months to years. now is the time to flatten this curve. unless we anticipate, plan and invest in all our secondary care mental health services as a priority, they will be overwhelmed with terrible consequences for the mental health and economic recovery of our country. the authors have no conflict of interest to disclose. the author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the helsinki declaration of , as revised in . the authors assert that ethical approval was not required for publication of this manuscript. this article received no specific grant from any funding agency, commercial or not for profit sector. online social media: new data, new horizons in psychosis treatment mental health in the covid- pandemic impact of the economic recession and subsequent austerity on suicide and self-harm in ireland: an interrupted time series analysis is schizophrenia research relevant during the covid- pandemic? schizophrenia research mental health care for university students: a way forward? the lancet psychiatry national vision for change working group, psychosocial & mental health needs following major emergencies. a guidance document. houses of the oireachtas committee on the future of healthcare reaching out in college 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employees in china: exposure, risk perception and altruistic acceptance of risk key: cord- -sfhwaqfr authors: henssler, jonathan; stock, friederike; van bohemen, joris; walter, henrik; heinz, andreas; brandt, lasse title: mental health effects of infection containment strategies: quarantine and isolation—a systematic review and meta-analysis date: - - journal: eur arch psychiatry clin neurosci doi: . /s - - -x sha: doc_id: cord_uid: sfhwaqfr due to the ongoing covid- pandemic, an unprecedented number of people worldwide is currently affected by quarantine or isolation. these measures have been suggested to negatively impact on mental health. we conducted the first systematic literature review and meta-analysis assessing the psychological effects in both quarantined and isolated persons compared to non-quarantined and non-isolated persons. pubmed, psycinfo, and embase databases were searched for studies until april , (prospero registration-no.: crd ). we followed prisma and moose guidelines for data extraction and synthesis and the newcastle–ottawa scale for assessing risk of bias of included studies. a random-effects model was implemented to pool effect sizes of included studies. the primary outcomes were depression, anxiety, and stress-related disorders. all other psychological parameters, such as anger, were reported as secondary outcomes. out of screened articles, studies were included in our analyses. compared to controls, individuals experiencing isolation or quarantine were at increased risk for adverse mental health outcomes, particularly after containment duration of week or longer. effect sizes were summarized for depressive disorders (odds ratio . ; % ci . – . ), anxiety disorders (odds ratio . ; % ci . – . ), and stress-related disorders (odds ratio . ; % ci . – . ). among secondary outcomes, elevated levels of anger were reported most consistently. there is compelling evidence for adverse mental health effects of isolation and quarantine, in particular depression, anxiety, stress-related disorders, and anger. reported determinants can help identify populations at risk and our findings may serve as an evidence-base for prevention and management strategies. electronic supplementary material: the online version of this article ( . /s - - -x) contains supplementary material, which is available to authorized users. quarantine and isolation are main containment strategies intended to help protect the public by preventing the spread of contagious diseases. both strategies primarily refer to a restriction of movement and limitation of personal contacts [ ] . quarantine, per definition, is used for persons that may have been exposed to the disease, while isolation is used for contagious persons that require separation from persons who are not infected. findings from previous research pointed towards an increased risk for negative psychological outcomes, such as depression and anxiety, through isolation [ ] [ ] [ ] . quarantined persons may equally be at heightened risk for adverse mental health outcomes. a rapid review by brooks et al. reported increased negative psychological outcomes including post-traumatic stress symptoms, confusion, and anger in persons under quarantine [ ] . the authors concluded that important stressors were longer quarantine electronic supplementary material the online version of this article (https ://doi.org/ . /s - - -x) contains supplementary material, which is available to authorized users. duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma [ ] . findings suggest that both containment strategies, quarantine and isolation, have negative impacts on psychological outcomes related to a broad spectrum of psychosocial stressors [ ] [ ] [ ] [ ] . the need for investigation of mental health problems associated with containment strategies is further highlighted by the rising implementation of quarantine and isolation worldwide due to the currently ongoing covid- pandemic. an unprecedented number of people worldwide is affected by quarantine or isolation [ ] . the identification of individuals at elevated risk for adverse mental health effects seems mandatory. it has been suggested that vulnerable populations at risk for negative psychological outcomes before implementation of containment strategies, e.g. persons with mental illness, low income, or lack of social network, may be at particular greater risk during and after quarantine or isolation [ ] . the world health organization (who) has included covid- in the list of diseases and pathogens prioritized for research and development (r&d) in public health emergency contexts, which pose the greatest public health risk due to their epidemic potential, as insufficient countermeasures have been established [ ] . containment strategies are among the main countermeasures in this context [ ] and systematic investigation of evidence concerning their psychological effects is urgently in need. single studies and reviews [ , ] suggest an increased risk of negative psychological outcomes in persons under quarantine or isolation, but others presented partially contradicting results [ , ] . furthermore, prevalence estimates point towards elevated levels of adverse outcomes in quarantined or isolated populations [ ] , however, validity of these findings is often limited by the underlying uncontrolled study design. we, therefore, conducted a systematic literature review and meta-analysis of the mental health effects of quarantine and isolation, based on controlled primary study data. to the best of our knowledge, no meta-analysis including both quarantine and isolation exists to date. this is a systematic literature review and meta-analysis. the protocol of the project has been published on prospero (prospero registration-no.: crd ). methods followed guidelines by the cochrane collaboration for the conduction of systematic reviews [ ] . we searched pubmed, psycinfo, and embase databases for studies with no restrictions, from the beginning of the searched time period and until april , , assessing the rate of psychological effects in quarantined/isolated persons compared to non-quarantined/non-isolated persons. search entry is described in an online supplement (supplement . database search entry). broad and specific search terms were combined to increase the likelihood of detecting eligible studies for our research aim. among the specific search terms, we included a list of diseases and pathogens prioritized for research and development (r&d) in public health emergency contexts by the world health organization (who), such as covid- [ ] . additional records were identified through manual searches of references of the included studies. we included no language restrictions and translations by a native speaker were acquired to test eligibility criteria of articles in languages other than english. study authors were contacted in case of missing data. the search was carried out using endnote x . (clarivate analytics, philadelphia, usa). trials were considered appropriate to test the hypothesis and included when they met the following criteria. first, observation of persons in quarantine or isolation was described. second, quantitative assessment of psychological outcome parameters was performed. third, comparators were persons not in quarantine or isolation. fourth, data for the calculation of effect sizes and corresponding measures of dispersion were provided. studies observing psychological outcome parameters by qualitative assessment only were excluded. studies were excluded if they focused on specific subpopulations without primary infection control-association, such as isolated persons in prisons. studies assessing correlations of mental health outcomes with varying durations of quarantine or isolation only were excluded from quantitative synthesis and reported in our qualitative synthesis of determinants. the entire literature search and study screening were carried out independently by two reviewers (fs, jvb). consensus in unclear cases was reached via discussion with additional members of the reviewing team (lb, jh). testing of eligibility criteria, study selection, and classification and coding of data into a predefined excel spreadsheet (microsoft excel for mac, version . , microsoft corporation, usa) followed recommendations by the cochrane collaboration handbook [ ] and were performed independently by two reviewers (lb, jh). two reviewers (jh, lb) independently extracted data regarding characteristics of the study and study samples, as well as quantitative data on severity (mean scores) or frequency (incidence or prevalence) of mental health outcomes for each group or for the comparison between groups (e.g. relative risk, odds ratio), and the results of any determinant testing reported to reach statistical significance in the original studies. when multiple measures for the same outcome were reported, we extracted data in the following hierarchy: ( ) continuous measures (mean scores), ( ) categorical measures using the highest cut-offs defined by the authors of the original studies (i.e. the most severe manifestation of the disorder). risk of bias of studies was classified independently by two reviewers (lb, jh) according to the newcastle-ottawa scale (nos) [ ] as recommended by the cochrane handbook [ ] (table ) . by summary assessment, all studies were classified as holding low or unknown/high risk of bias by taking into account bias from the three main domains selection, comparability, and exposure/outcome. disagreements were resolved by consensus with additional review authors. we calculated standardized mean differences (smd) and % confidence intervals (cis) from outcome measures of the primary studies. if respective measures of dispersion were not available, we calculated cis from p values as recommended in the cochrane handbook [ ] . stratified by our pre-defined mental health outcomes, effect sizes for comparisons between quarantined/isolated and non-quarantined/isolated groups were summarized using forest plots and tables. a quantitative synthesis of all these results was not possible due to the heterogeneity of the included studies in methodology, populations, and outcomes. we, therefore, restricted quantitative syntheses to our pre-defined outcomes and to primary studies that provided data on categorical outcomes based on validated diagnostic criteria for mental disorders. from these, we calculated summary estimates (odds ratio and % ci) using randomeffects models (dersimonian and laird method), as the studies differed in several methodological aspects. effect sizes from different, non-overlapping subgroups of populations within a study were pooled using a fixed-effect model, as recommended in the cochrane handbook [ ] (three-level meta-analytic approach). heterogeneity among studies was quantified with the i statistic. analyses were conducted according to the cochrane collaboration handbook [ ] and using comprehensive meta-analysis v (biostat, engelwood, new jersey). descriptive text was used to summarize the results of any determinant testing reported to reach statistical significance in the original studies. after screening of titles and abstracts of articles, full-texts were assessed for eligibility. of these, studies, published between and , were eligible for quantitative synthesis (fig. ). studies observed isolation procedures, studies observed quarantine procedures and one study observed quarantine and isolation procedures. mean length of containment measures ranged from to . days (table ) . three additional studies provided data on determinants only and were not included in quantitative synthesis [ ] [ ] [ ] . pre-defined primary outcomes were depression, anxiety, and stress-related disorders. figure presents effect sizes from all studies providing data for these outcomes. secondary outcomes were all other mental health outcomes, as presented in fig. . quantitative synthesis of our pre-defined outcomes took into account primary study data on categorical outcomes based on validated diagnostic criteria for mental disorders (fig. ) . compared to non-quarantined/-isolated controls, individuals experiencing isolation or quarantine were at higher risk of depressive disorders (or . ; % ci . - . ; i : . %), anxiety disorders (or . ; % ci . - . ; i : . %), and stress-related disorders (or . ; % ci . - . ; i : . %). final ratings after assessment of methodological quality of included studies are summarized in table . out of studies were considered to be of low risk of bias. sensitivity analyses, restricted to studies of higher methodological rigor (i.e. low risk of bias), supported our main findings, i.e. an increase in all primary outcomes was observed in both quarantine and isolation. both containment measures determined adverse mental health outcomes. driven by the unequal number of available studies per group (i.e. quarantine or isolation), evidence-base is particularly strong for elevated levels of stress-related disorders in quarantined individuals and for depression and anxiety in isolated individuals (fig. ). determinants of psychological outcomes, reported to reach statistical significance in the primary studies, were: (results are from study, if not otherwise specified). younger age was associated with higher risk for stressrelated disorders/ptsd ( studies [ ] [ ] [ ] ), whereas persons > years were at higher risk for depression [ ] . women were at higher risk for depression [ ] , ptsd [ ] , and general mental health impairments [ ] ( study each), while men were found to be at higher risk for (non-psychotic) psychological disorder of any kind [ ] and at higher risk for alcohol use disorder [ ] ( study each). lower levels of education were associated with more severe symptoms of stress-related disorders/ptsd [ ] and higher risk of depression [ ] ( study each). lower household income and financial loss or economic impact in pandemics was correlated with a higher risks for negative psychological effects, i.e. depression ( studies [ , ] ), anxiety [ ] , anger [ ] , symptoms of stress-related [ ] , and unspecified psychological disorders [ ] ( study each). lower income was also associated with higher persistence of symptoms of ptsd over years [ ] . interestingly, higher household income was associated with higher risk of alcohol use disorder [ ] . low levels of social capital, lower perceived social support, and lower neighborhood relationships were associated with higher levels of depression ( studies [ , ] ) as well as anxiety, stress, and poor sleep quality ( study [ ] ). being single also determined higher levels of depression [ ] and higher persistence of ptsd symptoms over years [ ] ( study each). health care workers (hcw) experienced higher levels of stigmatization [ ] . one study reported higher levels of anger and anxiety with use of mail/texting and internet but not with telephone use in isolated, non-infected individuals [ ] . previous mental illness and psychiatric inpatient admission was associated with greater anxiety ( studies [ , ] ) and anger [ ] levels. a history of trauma determined higher risk of depression [ ] . depression and ptsd symptoms and a history of alcohol use as a coping strategy were associated with a higher risk of consecutive alcohol use disorder [ ] . lower perceived current health status was associated with higher levels of depression [ ] . exposure to infected individuals (e.g., friends/relatives or patients for hcw) and higher perceived risk of infection were associated with higher rates of adverse mental health outcomes: risk of adverse mental health effects was highest with having been infected oneself [ , ] . health care workers (hcw) were at higher risk compared with administrative personnel and hcw were at higher risk the more intense they worked with infected patients. this association was reported for anxiety and anger [ ] , depression ( studies [ , ] ), stress-related disorders/ptsd ( studies [ , , ] ), emotional exhaustion ( studies [ , ] ), insomnia [ ] , alcohol use disorder (aud) [ ] , and any psychological disorders [ ] . hcw with infection-related tasks were also reported to be at higher risk for persisting symptoms of ptsd one month after the end of infection containment measures [ ] . perception of the risk of health hazards due to infection was associated with a higher risk of symptoms of stress-related disorders/ptsd [ ] . for isolated/quarantined individuals, dissatisfaction with containment measures, supply, or the relationship to healthcare-personnel was associated with higher levels of anxiety and anger [ ] , stress-related disorders/ptsd ( studies [ , ] ) and lower general mental health [ ] . for hcw, lower trust in equipment and infection control initiatives determined higher levels of anger and emotional exhaustion, whereas higher organizational support was associated with lower anger and lower avoidance behavior [ ] . increased length of quarantine or isolation positively correlated with higher levels of anger ( studies [ , ] ), anxiety [ ] , avoidance behavior [ ] and stress-related disorders/ ptsd [ ] . independent of infection status, isolation was found to have negative psychological effects after and particularly after weeks [ ] . some studies [ , ] did not find negative mental health effects in isolation of - days duration, whereas others [ , , ] did. altruistic acceptance of infection-risk was reported to be protective against depression [ ] and stress-related disorders/ptsd [ ] . increased perceived stress was associated with higher levels of depression and anxiety [ ] . selfesteem and sense of control were inversely correlated with anxiety and depression [ ] . children of parents with symptoms of ptsd had themselves an elevated risk for ptsd [ ] . this systematic review and meta-analysis yielded the following main results: individuals experiencing quarantine or isolation are at heightened risk of depression, anxiety, stressrelated disorders and anger compared to non-quarantined or non-isolated persons. data for other mental health outcomes mainly resulted from single trials, but likewise strongly and coherently indicated increased adverse mental health effects in quarantined and isolated individuals. the included studies were heterogeneous in methodology, definition of containment strategies, and outcome parameters. determination of exact risk estimates is, therefore, limited and pooled effect size estimates should only serve as guiding values. in spite of this cautionary remark, our results provide compelling evidence for increased adverse mental health outcomes in isolated or quarantined individuals. sensitivity analyses, restricted to studies of higher methodological rigor, supported the main findings. thus, even in light of the methodological diversity of the included studies, findings appear to be sufficiently robust to impact on and inform clinical decision-making. since only studies were considered "low" risk of bias, more studies of high methodological rigor are needed to determine precise risk estimates. our general findings are in line with previous research: brooks et al. performed a rapid review of the literature including qualitative data and concluded that post-traumatic stress symptoms, confusion, and anger appear to be increased in persons under quarantine [ ] . in the same vein, cases of suicide associated with quarantine were reported during an outbreak with severe acute respiratory syndrome (sars) outbreak - [ ]. purssell et al. previously reported increased rates of anxiety and depression in hospital-isolated patients [ ] . these findings confirm an increased risk of mental health problems for persons under quarantine or isolation. to some extent, heterogeneity in observed effects from included studies may be attributable to different durations of quarantine or isolation. some studies [ , ] did not find negative mental health effects in isolation of - days duration, but others [ , , ] did. after periods of and particularly of weeks, however, evidence for adverse mental health effects of isolation and quarantine becomes increasingly solid [ , , ] . our analyses of determinants overall indicated that persons with higher levels of psychosocial vulnerabilities and stressors appear to be at particular risk for negative psychological outcomes associated with quarantine and isolation. this is in agreement with previous findings, indicating that the association between stress and mental health problems is determined by a variety of psychological, behavioral, and biological determinants including psychosocial resources, patterns of coping, and comorbidities [ ] . our review suggests that lower levels of education [ , ] , low income and financial loss [ , , , , ] , and lack of social networks are important determinants of negative psychological outcomes including depression, anxiety, and stress-related disorders, partly persisting over years [ ] . histories of mental illnesses or previous traumas likewise were factors associated with an increased risk of adverse mental health outcomes, highlighting the importance of particular awareness towards the vulnerability of these individuals during quarantine or isolation. importantly, studies that corrected for levels of psychological outcomes at baseline still detected increasing levels of negative psychological outcomes following with containment strategies [ , ] . even beyond that, however, persons with mental health disorders may experience increased difficulties in accessing mental health services, as well as day care centers and psychosocial networks, which are important for mental health outcomes. in line with previous studies [ ] emphasizing the negative impact of social isolation and exclusion stress on mental disorders, containment procedures may, therefore, represent an independent risk factor for adverse mental health effects and are likely to affect larger parts of the general population. this independent risk factor, however, may particularly add up to pre-existing vulnerability. we found cumulated evidence for elevated levels of anger in populations under quarantine or isolation, even increasing with ongoing duration of containment [ , ] . this is of particular relevance during the current worldwide covid- pandemic, as could be shown by concerns of increasing domestic violence and child abuse based on initial reports in populations affected by covid- quarantine in asia and europe [ , ] . a major important finding is the elevated risk of negative psychological effects for healthcare workers, particularly those with exposure to infected patients [ , , , , , , , , , ] . awareness has to be drawn to the finding [ ] that their risk of negative psychological effects was determined by the perception of personal health hazards, organizational support, and trust in equipment, outlining the path for crucial prevention and management strategies to minimize adverse mental health effects for healthcare workers. this review has several strengths and limitations. strengths include the extensive database search and the duplication of screening, data extraction, and the thorough evaluation of the methodology and risk of bias of the studies. also, by restricting eligibility of primary studies to those that used non-quarantined/-isolated populations as a comparator, we were able to calculate relative effect estimates with higher explanatory power. however, this review also has several limitations. studies reporting psychological outcomes only as secondary outcomes may not have been identified in the searches of electronic publication databases if these psychological outcomes were not reported in the title, abstract, keywords, or indexing terms. the use of the three large and relevant databases in this field and supplementary manual searches of all reference lists of included studies and related articles, however, should have minimized the risk of missing relevant studies. our meta-analysis confirmed the initial assumption that persons under quarantine or isolation are at risk for mental health problems. the representativeness and validity of our findings are, however, limited by the following aspects: limitations of the currently available evidence include ( ) partial use of cross-sectional study designs, thus making temporality of events difficult to assess, ( ) lack of power, and ( ) frequent lack of consideration for important confounders, such as baseline mental health status. the majority of included studies investigated singleperson isolation measures. the scarcity of studies focusing specifically on quarantine in general population settings is a limitation of the current evidence and has to be accounted for when generalizing the findings of our meta-analysis. additionally, during times of a pandemic, such as the current covid- pandemic, populations may experience various degrees of restricted movement or limited personal contacts that do not necessarily coincide with systematically implemented quarantine or isolation. clearly, conduction of adequately controlled studies is particularly challenging with regards to population-based quarantine measures. our findings, however, are in accordance with and strengthened by results from additional uncontrolled studies [ , , ] , indicating that these differential containment strategies share indeed common adverse mental health effects. more research is needed to assess the differential effects of various degrees of movement restrictions and contact limitations on psychological outcomes in single person as well as population-based settings. moreover, the studies in this meta-analysis are heterogenous with regard to study designs including definitions of the containment strategy, populations, and outcome parameters. drawing conclusions from this meta-analysis to different subpopulations, such as children and geriatric subpopulations, and different procedures for implementing quarantine or isolation is, therefore, limited and should consider characteristics of the specific population and its specific reaction to a clearly defined containment strategy. psychosocial factors relevant for the reaction to containment strategies and resulting mental health problems may significantly differ between subpopulations. to date, however, there is very limited specific evidence for each of the subpopulations only. more controlled studies for specific subpopulations categorized according to mental and physical health, social support, and economic status are needed to further assess the generalizability of the findings. generalizability would be further increased by implementation of standard diagnostic criteria of mental health problems, such as the diagnostic and statistical manual of mental disorders (dsm) [ ] or the international statistical classification of diseases and related health problems (icd) [ ] . persons under quarantine or isolation appear to be especially vulnerable for mental health problems associated with psychosocial adversities, such as social isolation, financial loss, inadequate supplies and information, stigma, and fear of infection [ ] . this systematic review of the evidence identified a full range of adverse psychological effects in persons under quarantine or isolation. further investigation should focus on the identification of moderating and protective factors and the development of effective prevention and management strategies aligned to populations of particular vulnerability. psychosocial challenges associated with containment strategies are of exceptional relevance due to the ongoing covid- pandemic and the resulting frequent implementation of quarantine and isolation. implementation of containment strategies should, thus, include consideration of increasing negative psychological outcomes associated with especially long durations of quarantine and isolation. large groups of the general population may be affected, but individuals who are already facing psychosocial adversities before quarantine or isolation (including persons with low income, lack of social networks, or mental health problems) appear to be among those vulnerable groups at greatest risk for negative psychological outcomes. health care workers showed a strong increase in negative psychological outcomes and stigma [ ] . these effects might even be stronger in the ongoing covd- pandemic taking into account that current measures of quarantine and in particular isolation are longer and affect large populations worldwide. based on these findings, potential negative effects on mental health outcomes from infection containment strategies may possibly be reduced by several measures. our findings highlight the need for organizational structures that can adapt to crisis management, sufficient equipment, and support for health care workers. evidence strongly supports the inverse relationship between trust in equipment or organizational support and adverse mental health effects in this population at particular high risk for negative psychological outcomes. for persons with mental health disorders, maintenance of access to mental health care services should be of high priority. targeted mental health prevention and intervention strategies for these populations at risk are urgently needed [ ] . moreover, the findings of this meta-analysis support the implementation of recently recommended measures to mitigate the potential negative psychological effects of quarantine, such as keeping the duration of the containment as short as possible, but as long as needed, providing adequate supplies for basic needs for quarantined households, providing persons with as much information as possible regarding the reason for the quarantine, and effective and rapid communication [ ] . persons under quarantine or isolation are at heightened risk of mental health problems, in particular depression, anxiety, stress-related disorders and anger. experiencing quarantine or isolation was found to represent an independent risk factor for adverse mental health outcomes. these findings highlight the need for mental health prevention strategies for populations at risk, particularly health care workers exposed to infection and individuals who already were facing psychosocial adversities before quarantine or isolation including those with low income, lack of social networks, or mental health problems. author contributions jh and lb had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. concept and design: jh, ah, and lb. acquisition, analysis, or interpretation of data: jh, fs, jvb, hw, ah, and lb. drafting of the manuscript: jh, ah, and lb. critical revision of the manuscript for important intellectual content: jh, fs, jvb, hw, ah, and lb. statistical analysis: jh and lb. obtained funding: none. supervision: ah. funding open access funding enabled and organized by projekt deal. this study was supported in part by the collaborative research centre trr (crc-trr ). henrik walter has received funding from the european union's horizon research and innovation programme under grant agreement no . this publication reflects only the authors' view and the european commission is not responsible for any use that may be made of the information it contains. conflict of interest the author(s) declare that they have no competing interests. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/ . /. learning from sars: preparing for the next disease outbreak-workshop summary impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis adverse effects of isolation in hospitalised patients: a systematic review mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence the psychological impact of quarantine and how to reduce it: rapid review of the evidence covid- -the law and limits of quarantine world health organization 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factors influencing compliance with quarantine in toronto during the sars outbreak diagnostic and statistical manual of mental disorders world health organization ( ) international statistical classification of diseases and related health problems, th edn do contact precautions cause depression? a two-year study at a tertiary care medical centre association between contact precautions and delirium at a tertiary care center psychological impact of the management of methicillin-resistant staphylococcus aureus (mrsa) in patients with spinal cord injury effects of isolation on patients and staff methicillin-resistant staphylococcus aureus: psychological impact of hospitalization and isolation in an older adult population key: cord- -ivj imsk authors: patel, vikram title: empowering global mental health in the time of covid date: - - journal: asian j psychiatr doi: . /j.ajp. . sha: doc_id: cord_uid: ivj imsk nan i could hardly have imagined that mental health would have become such a commonly sought after topic in a world gripped by the fear of a marauding virus. never before have i seen so many webinars, so many pundits, and so many listeners on this topic. but then, we live in times where so much of what we took for granted has been thrown under the bus. who could have imagined even just a few months ago that much of the world would be looking down the barrel of an economic recession unlike any witnessed in our lifetime? but let me be clear about one thing: mental health has become a key concern globally not because of any direct impact of the virus, but as a consequence of the reaction of the media and governments to the epidemic. just the word 'pandemic' and the dramatic way it was announced by the who after weeks of the epidemic unfolding around the world was a hairraising moment. then, there was the apocalyptic messaging by modellers about the millions of dead bodies that would be littering our cities and by the media on the risk the disease posed-for example failing to communicate that the median age of death was in the mid- s; emerging data demonstrating the vast number of asymptomatic individuals suggests the overall mortality rate is well below %, falling to nearly zero in young people. the ghoulish reporting of cases, without any nuancing about what those numbers actually mean, served to confirm in people's minds that the virus was inexorably sweeping the world. the final nail in the coffin were the unprecedented national lockdowns, nowhere as brutal, unplanned and sweeping as the one in india, announced with just four hours' notice late in the evening, with a scope and stringency that has never been seen in history. in this context, unless you are an epidemiologist who is well-informed to correctly interpret the numbers and read between the lines, the wide-spread reactions of panic and fear are totally understandable. indeed, if one considers the constant uncertainty about when, if ever, life will return to a semblance of what we used to experience, the torrent of mixed messages about the science (real or fake) around the virus, and the complete lack of consensus on what the post-lockdown scenario for the containment of the virus might look like, i think it might even be somewhat unexpected for an individual to report being in great mental health in these times! it is not at all surprising that experiences of anxiety, fearfulness, sleep problems, irritability and feelings of hopelessness have become widespread. they are mostly rational responses of our minds to the extraordinary realities that we are facing. that said, if the curve of the severity of mental health symptoms (apologies to those who are fed up of seeing the word 'curve') has shifted to the right, i.e. towards greater severity, one will also be seeing a rising incidence of clinically significant mental health problems and suicide, as was observed in a previous coronavirus epidemic in hong kong (cheung, chau, & yip, ) . furthermore, thanks to lockdowns and the pivoting of health care services to this one virus, there is emerging evidence that routine mental health care has been seriously disrupted affecting not just incident illness episodes but also the continuing care of preexisting mental health problems. certainly, a rise in the burden of clinically significant mental health problems is what we should expect as the impact of the economic recession, the widening of inequalities in countries, the continuing uncertainties about future waves of the epidemic and the physical distancing policies begin to bite deeper into our mental health. this would not be surprising, given the strong association between unemployment, acute poverty and indebtedness with poor mental health (lund et al., ) . "deaths of despair" have been documented as the cause for the increased mortality and reduction in life expectancy in working-age americans following the economic recession in (case & deaton, ) . tracing the source of these deaths ultimately to a deeply unfair economic system, the authors point out that these deaths were not so much due to material hardship but because of loss of hope due to the lack of employment and rising inequality. suicide and substance use related mortality accounted for most of these deaths. many low and middle income countries share the ills of us society, from its profound inequality to its weak social security net and fragmented health care systems; in addition, these countries are also home to the largest number of poor people in the world, already enfeebled by hunger and myriad diseases of poverty. this toxic combination of absolute poverty with rising levels of inequality is a recipe for a similar surge of depths of despair in the region. mental health care systems in most countries will be illequipped to deal with this surge, not only because of the paucity of skilled providers, but also because of the narrow biomedical models which dominate mental health care. while there has been a flourishing of initiatives to address the rising tide of mental health problems, most notably through telemedicine platforms, these suffer from the same barriers that have so limited the coverage of mental health care in the past: most rely on specialist providers who are very scarce in number. this is compounded by yet another barrier: digital literacy and adequate internet connectivity still remains a distant goal for large swathes of the world's people, particularly amongst the poor and rural populations. still, one welcome aspect of this development is the recognition of the possibility of remote delivery and the value of psychological therapies, often ignored in mental health care and, at best, playing a poor cousin to medication options. at the same time, low-resource settings have been a laboratory for some of the most transformative innovations to improve access to evidence based psychological therapies in psychiatry with a flurry of randomized controlled trials for depression, psychoses and harmful drinking reframing the way we can enhance the coverage of these interventions. this critically important clinical and implementation science is now influencing global policies and, incredibly, also the way mental health care is organized in rich countries which enjoy so much more mental health resources. the impressive body of evidence generated by global mental health researchers has generated a range of innovative strategies aimed at addressing the structural barriers to the scaling up of psychosocial therapies, notably the demonstration that pared down 'elements' of complex psychological treatments packages can be just as effective as standardized treatment protocols (for e.g. behavioural activation for depression, compared with cognitive behaviour treatments); that providers can be trained to learn a library of such 'elements' targeting specific types of mental health experiences (for example, mood problems, anxiety problems, trauma related problems) and to use simple decision making algorithms to 'match' patients' problems with specific treatments elements; that one does not require a formal diagnosis to trigger care, greatly simplifying the dissemination of effective treatments; that these pared down treatments elements and trans-diagnostic protocols can be effectively delivered by non-specialist "therapists", such as community health workers; that these delivery models are highly acceptable to consumers; show recovery rates comparable to specialist care models, and economic analyses show they are excellent value for money (kohrt et al., ; singla et al., ) . more recent innovations seeking to scale up these approaches demonstrate the acceptability and effectiveness of digital training in the delivery j o u r n a l p r e -p r o o f of psychological treatments and of peer supervision for quality assurance (muke et al., ; singla et al., ) . this range of innovations, when combined and scaled up, can transform access to one of the most effective interventions in medicine. this is exactly the goal of the empower program, an initiative of harvard medical school (https://globalhealth.harvard.edu/empower-building-mental-health-workforce) which is seeking to scale up evidence based psychological therapies, with an initial implementation focus on communities in the usa and india. over the coming years, we intend to build on the ongoing work of the essence program, a nimh funded research hub, led by sangath in partnership with the government of madhya pradesh, to digitize the curriculum of a brief behavioural activation treatment for depression (patel et al., ) , its competency assessments and the supervision and quality assurance protocols. ultimately, this platform will offer a career path which enables front-line providers an opportunity to achieve the status of an expert, motivating them and ensuring sustainability of the most expensive mental health professional resource. future enhancements include evaluating the effectiveness of the scaling up on population mental health and harnessing big data opportunities to develop prediction models to refine treatment element selection algorithms to optimize patient outcomes. the use of digital platforms for building the workforce is not only aligned with the use of tele-medicine but also with the urgent need for digital approaches for training and supervision in the light of physical distancing policies. but, of course, implementers will need significant resources to realize these kinds of ambitious projects and here we need to anticipate the biggest threat to mental health consequent to covid : the pushing back, once again, of mental health from the global health agenda. i recall this happening way back in the late s when it appeared that mental health would finally be recognized as a priority by the world's leading development agencies only for it to be left off the table by the millenium development goals of . fifteen years later, mental health found its rightful place in the sustainable development goals and i could begin to sense its inclusion in the priorities of funders who had previously given it a pass. and now we are in the first half of and all funding and health care action has entirely pivoted towards one disease-covid . already some of the funding i had come close to securing for empower has been stalled. and some of it may never be realized. it is deeply worrying that despite the strong mental health concerns in the light of the pandemic, there seems to be no meaningful role played by mental health professionals in guiding public policies on the epidemic. once again, mental health risks are being shoved back into the shadows. this is a timely moment for diverse stakeholders concerned with mental health, from psychiatric associations and global mental health practitioners to civil society advocates, to unite with one message, that the pandemic and its socio-economic consequences will have profound effects on population mental health and that some of the financial resources being pumped into the covid response must be allocated to 'build back better' mental health care systems in all countries. j o u r n a l p r e -p r o o f deaths of despair and the future of capitalism a revisit on older adults suicides and severe acute respiratory syndrome (sars) epidemic in hong kong the role of communities in mental health care in low-and middle-income countries: a meta-review of components and competencies social determinants of mental disorders and the sustainable development goals: a systematic review of reviews acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural india the healthy activity program (hap), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in india: a randomised controlled trial psychological treatments for the world: lessons from low-and middle-income countries improving the scalability of psychological treatments in developing countries: an evaluation of peer-led therapy quality assessment in goa, india key: cord- -nrhe aek authors: shah, kaushal; mann, shivraj; singh, romil; bangar, rahul; kulkarni, ritu title: impact of covid- on the mental health of children and adolescents date: - - journal: cureus doi: . /cureus. sha: doc_id: cord_uid: nrhe aek the coronavirus disease (covid- ) outbreak was first reported in wuhan, china, and was later reported to have spread throughout the world to create a global pandemic. as of august th, , the coronavirus had spread to more than countries with at least , , confirmed cases, resulting in , deaths globally. several countries declared this pandemic as a national emergency, forcing millions of people to go into lockdown. this unexpected imposed social isolation has caused enormous disruption of daily routines for the global community, especially children. among the measures intended to reduce the spread of the virus, most schools closed, canceled classes, and moved it to home-based or online learning to encourage and adhere to social distancing guidelines. education and learnings of . % of students are impacted globally due to coronavirus in countries. the transition away from physical classes has significantly disrupted the lives of students and their families, posing a potential risk to the mental well-being of children. an abrupt change in the learning environment and limited social interactions and activities posed an unusual situation for children's developing brains. it is essential and obligatory for the scientific community and healthcare workers to assess and analyze the psychological impact caused by the coronavirus pandemic on children and adolescents, as several mental health disorders begin during childhood. countries across the globe, including the united states, are in the dilemma of determining appropriate strategies for children to minimize the psychological impact of coronavirus. the design of this review is to investigate and identify the risk factors to mental health and propose possible solutions to avoid the detrimental consequence of this crisis on the psychology of our future adult generations. since the first reported coronavirus case in wuhan, china, in , the outbreak, now known as covid- , has spread globally [ ] . the world health organization (who) acknowledged this coronavirus epidemic as a pandemic and declared the outbreak as a public health emergency of international concern [ - ]. most regions around the world are affected severely, including the united states, brazil, india, russia, and europe, which have seen an increasing number of cases and deaths than the rest of the world [ - ] . as of august th, , the coronavirus had spread to more than countries and has at least , , confirmed cases, resulting in , confirmed deaths globally. in the united states, between january th and august th, , there have been , , confirmed cases of covid- with , deaths [ ] . the spread of the virus has caused global economic and social disruptions and has brutally overwhelmed the healthcare and educational systems [ ] . the unexpected disruption of the social fabric and norms has affected the behavioral and mental health of the public, including children. the mental health of children has been influenced by several ways, as this unprecedented situation changed a way they typically grow, learn, play, behave, interact, and manage emotions. children with pre-existing psychiatric disorders such as attention-deficit/hyperactivity disorder (adhd), anxiety, depression, mood disorders, and behavior disorders could be adversely impacted during this stressful situation [ ] . mental disorders are the leading cause of disability worldwide in adolescents and children. about % of children and adolescents in the world have mental health disorders or conditions. nearly % of mental disorders start to affect the children by the age of . if left untreated, a child's mental development has been found to be drastically and detrimentally impacted. it is well established that mental health is one of the essential parts of human development and determines the outcome of a child's educational attainments and the potential to live fulfilling and productive lives [ ] . mental illness can affect children at any point during their childhood, but it most significantly affects them during adolescence. among the several mental illnesses that can be prevalent in childhood, depression is one of the major leading causes of mental illness amongst children. in , an estimated , deaths were due to adolescent suicide, which is the third leading cause of morbidity in this group. this emphasizes that adolescence is a period of vulnerability for the onset of mental health conditions [ ] . as of august th, , countries have closed schools and educational facilities worldwide due to the covid- pandemic, impacting , , , learners, consisting of about . % of students globally. it has forced several countries to implement home-based learning or online training [ ] [ ] [ ] . approximately . billion students and their families have been affected by school closures due to the pandemic. these students are experiencing further distress due to the unavailability of adequate help and attention from the trained instructors, making education more expensive for them and their families as they need to utilize additional time, support, and resources. due to the closing of schools, students' interaction and communication with school mates, play, exercises, and peer-activities are hindered, which have proven vital for the growth, development, and learning of the young human minds [ ] . the children who are at most significant risk are the youngest ones as their brains are still developing and are being exposed to high levels of stress and isolation, which can lead to permanent abnormal development. children exposed to stressors such as separation through isolation from their families and friends, seeing or being aware of critically ill members affected with coronavirus, or the passing of loved ones or even thinking of their own death from the virus can cause them to develop anxiety, panic attacks, depression, and other mental illnesses [ ] [ ] . the conducted literature search was through medline, pubmed, pubmed central, and embase using the keywords, 'coronavirus,' 'covid- ,' 'mental health,' 'child and adolescent,' 'behavioral impact,' 'psychological conditions,' 'quarantine,' and 'online education.' the indexed search aimed to identify literature and articles relevant to our focused topic. the objectives of this review article are . to understand the overall psychological impact of covid- on children and adolescents; . identifying factors contributing adversely to their mental health; and . proposing interventions based on the guidelines and evidence-based practices. the outbreak of covid- has disrupted the lives of many people across the world. the pandemic has imposed a sense of uncertainty and anxiety, as the world was unable to predict or prepare for this crisis. it has caused a tremendous stress level among children, adolescents, and all students in general, primarily due to the closure of their schools. this stress may lead to undesirable adverse effects on the learning and psychological health of students [ ] . children exposed to these incidents can precipitate the development of anxiety, panic attacks, depression, mood disorders, and other mental illnesses [ ] . distressing events such as separation from family and friends, seeing or being aware of critically ill members affected with coronavirus, or the passing of loved ones or even thinking of themselves perhaps dying from the virus would have a detrimental effect on the mental health. additionally, the healthy daily routines of children have been disrupted due to the covid- , which contributes to the additional stress and sleeping difficulties that many children face. uncertainty of their future ambitions, academics, personal relationships, and inactivity due to the pandemic poses a significant threat to their mental well-being and putting them at risk of drug abuse [ ] . covid- can seriously leave a negative impact on children's mental health, just like other traumatic experiences humans may face. it can lead to higher rates of depression, anxiety, and post-traumatic stress disorder. this causes fear in children because the virus threatens not just them but also their families and surroundings, especially as they see their parents working from home, leading to fear and shock [ ] . previous studies on severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers), and ebola have revealed that the disease causes severe emotional distress during the outbreaks. unfortunately, studies were not adequately conducted on the children and adolescents during the past outbreaks to measure its impact on their mental health, but several parallels can be drawn. the situation of covid- is comparable with the mers and sars, as similar claims made about the severity of mers caused fear, worry, and anxiety among the public. a study on the sars survivors with psychiatric disorders revealed that about % of the patients showed signs of post-traumatic stress disorder (ptsd), and . % of them had worsening depression [ ] . this finding corresponds to the increased suicide deaths among sars survivors, consisting of older adults from hong kong in and [ ] . among those mers survivors, lower quality of life was also noticed. neuropsychiatric linkage has been established based on the previous outbreaks [ ] . during this pandemic, children and their families have been exposed to direct or indirect factors that could pose stress and emotional disturbance. several weeks of homestay has forced parents and/or caregivers to work from home. also, many families lost their financial independence due to job losses [ ] . this disease is installing fear in children because children are worried about not only getting infected but also having their parents staying at home and not leaving for work [ ] . some families are struggling to feed their children, as many were dependent on school programs or food stamps, and not all families with resources can provide adequate supplies [ ] . however, the reach of the pandemic is unequal as numerous families have lost loved ones while others live in regions untouched by the virus. some children have parents who work on the front lines in covid- settings, and others have parents who now work from home or have recently been terminated [ ] . additionally, international students are impacted by uncontrollable factors such as school closure, campus closure, and travel restrictions. nations across the globe have restricted their borders to internationals to help mitigate the pandemic as many students might not have any other place to reside. this sudden closure of many nations to outsiders has placed a great burden on school administrators to ensure housing, sustenance, and safety of their international students [ ] [ ] . while transitioning to online classes has helped both international and national students to continue their education, several children and faculty members are experiencing distress because they may not have the technological capability or expertise required to navigate this new mode of interaction. the online teaching method has raised questions for the faculty about their capability to deal with the existing technology [ ]. the covid- pandemic has caused unprecedented health and humanitarian crisis. it has created an economic downturn due to the necessary measures to contain the spread of the virus. as per the latest global financial stability report, there is likely to be financial instability, which would lead to a devastating recession. the combined economic uncertainty and emotional distress placed on a family will challenge the overall well-being of families as well as their mental health [ ] . it is paramount to encourage and adopt healthy behavior to maintain the overall well-being of families. the well being of caregivers or parents can directly impact the mental health of the children. parents are advised to follow and practice the guideline provided by the world health organization (who). the who has urged people to follow social distancing guidelines and avoid close contact with anyone, especially from the person showcasing any respiratory symptoms [ ] . the health organization has also emphasized maintaining better hygiene by consistently washing hands and using appropriate protective gear such as facial masks [ ] . it has also advised to take breaks from watching, reading, or listening to news stories, including social media, because continually being bombarded by news of the pandemic can be distressing. exercising regularly, practicing yoga or meditation, eating healthy, taking adequate and proper sleeping properly, and avoiding alcohol or drugs is key to maintaining mental health. it is also crucial that parents provide enough support to their children and help them to process the information about the pandemic because these interventions could help minimize their anxiety or fear [ ] . schools, parents, and healthcare institutions can also implement psychological first aid (pfa) guidelines to assist children with their mental distress. pfa can provide psychosocial support to any survivors of epidemic or disaster [ ] . it is developed to mitigate acute distress and assess the need for more advanced psychiatric care. it is beneficial to implement it during the early stages of crisis to assist survivors in coping with grief and avoiding the long-term impact of stress on mental health. the 'rapid' model of the john hopkins pfa tool includes five steps, (i) r -rapport and reflective listening, implemented throughout the interaction; (ii) a -assessing and evaluating the psychological needs; (iii) p -prioritizing the needs based on severity; (iv) i -intervening to mitigate distressing factors; (v) d -disposition and distribution of intervention to stabilize the survivor [ ] [ ] . schools should emphasize the mental health of students by supporting and providing updated health organization guidelines through online lectures. also, a licensed counselor should help students manage the covid- related stress by providing coping mechanisms and strategies in both group and individual sessions. counseling services should be available to support the mental health and well being of students on time. universities can establish a task force to make a plan to reduce the spread of the virus and for the following centers for disease control and preventions (cdc) guidelines. the committee should include members from diverse professional backgrounds and experiences, such as public health department, physicians, psychiatrists, psychologists, social workers, administrators, health and human services, international services center, human resources, admission offices, enrolment, and billing department, athletic department, and teachers. to reduce the distress experienced by students and faculty related to information technology (it) issues, a technical team should be available continuously, and learning tutorial videos should be shared with the end-users. similarly, teachers and faculty should support students and their parents through clear communication and assigning clear expectations [ ] . a licensed counsel should take a comprehensive assessment of students deemed susceptible through risk factors such as psychological issues, including poor mental health before the crisis, bereavement, injury to self or family members, life-threatening circumstances, panic, separation from family, and low household income. minimizing the interruption of psychiatric care for patients with pre-existing conditions via telepsychiatry will be helpful to continue monitoring patients as the pandemic may worsen some patients' conditions and would adversely impact them if they were unable to contact their doctor. psychological assessment will help them to cope with their mental issues and stabilize their condition as they gain more education and discuss the impact of a pandemic. it will provide them support and reassurance to build resilience and encourage them to stay positive and motivated [ ] . mental health involves the regulation of our emotions, psychological, and social well-being. per the cdc, mental health affects how we think, feel, and act. it also helps determine how we react to stress, correlate with others, and our decision-making. mental health is significant throughout our lives, from early childhood to adolescence and through adulthood. mental illnesses occur when mental health is affected and leads to conditions that affect the way a person thinks, feels, or behaves, such as depression, anxiety, bipolar disorder, or schizophrenia. mental health can cause conditions that may be acute or chronic and alter the way we live our lives daily by our rationalizations. psychological and physical health are interdependent, both working together to form who we are. mental illness, especially depression, limits rational thinking, and increases the risk for other health problems such as diabetes. the presence of chronic conditions can increase the risk of mental illness. it is vital to strike a healthy balance between students' physical and psychological well-being [ ] . protecting and maintaining the mental health of the future adult generation is only possible with the robust schooling and healthcare system. it is necessary to have adequate resources to overcome this crisis. recruiting additional school personnel, clinicians, and mental health counselors are needed to address the strain on the system for supporting students during this pandemic [ ] [ ] . comprehensive school mental health systems (csmhss) is required to deliver adequate assistance for the students effectively [ ] . csmhss is a school-community association developed for all students to provide a variety of services for every type of students, such as mental health services, health promotion and prevention, early identification and interventions of diseases, and treatments for students evidence-based medicine [ ] . the csmhss should be enabled to collaborate with counselors, community mental health, and physical healthcare providers to help prevent mental health issues and make necessary referrals through an online interface for the treatment. the recruitment of additional school personnel and mental health counselors will help the students manage their anxiety, depression, and/or stress due to covid- ; and to stabilize any previously diagnosed mental illness or prevent new mental illness from developing [ , ] . moreover, children with inadequate information about why quarantine measures have been taken are found to have more anxiety. therefore, it is essential to expose children to more information about covid- through several sources, such as the evening news [ ] [ ] . this will make children more aware of the reason behind not only why quarantine measures were put in place, but they will also learn more about what covid- is. parents and guardians are encouraged to speak with their children about the information they learned, which may help lessen the negativity associated with covid- and quarantine. additionally, communicating with children about how they are processing the information will provide children with the emotional tools they require to do well in quarantine [ ] . not only can parents inform children about quarantine, but they can also employ "positive parenting" [ ] . children are prone to observe parents' and family members' moods during quarantine, which the children react to. through positive parenting, parents, guardians, and family members can create consistent daily routines to avoid the distress of unstructured days [ ] [ ] . while parents can provide a deeper understanding of the covid- and quarantine, school systems can provide further reassurances and educate children about emotions [ ] . school systems have the unique opportunity to provide consistent information to a large student body, who is unable to access other mental health programs in the areas [ ] . furthermore, school systems must adapt to the new online learning method and help students adjust and thrive in online classes [ ] [ ] . additionally, children can be taught coping mechanisms to self-regulate their own emotions without dependence on others. one method that achieves this goal is behavioral activation, which focuses on participating in activities they enjoy and not employing avoidance behaviors [ ] [ ] . alongside the other interventions mentioned above, behavioral activation can help children improve their problem-solving skills by engaging in healthy behaviors rather than unhealthy ones [ ] . due to the isolation indirectly imposed by the pandemic, children would be expected to prosper better in these times when they are taught ways to help themselves [ , ] . the epidemiology and clinical information about covid- covid- strategy update children's mental health child and adolescent mental health adolescent mental health empowering students with disabilities during the covid- crisis covid- is hurting children's mental health coping with stress as coronavirus prompts colleges to close, students grapple with uncertainty long-term psychiatric morbidities among sars survivors a revisit on older adults suicides and severe acute respiratory syndrome (sars) epidemic in hong kong coronavirus: universities are shifting classes online -but it's not as easy as it sounds covid- crisis poses threat to financial stability focus on mental health during the coronavirus (covid- ) pandemic: applying learnings from the past outbreaks sustainability of psychological first aid training for the disaster response workforce the johns hopkins model of psychological first aid (rapidpfa): curriculum development and content validation the role of psychological first aid to support public mental health in the covid- pandemic guidance to states and school systems on addressing mental health and substance use issues in schools how essential is to focus on physician's health and burnout in coronavirus (covid- ) pandemic? lifetime prevalence of mental disorders in u.s. adolescents: results from the national comorbidity survey replication-adolescent supplement (ncs-a) lifetime prevalence and age-of-onset distributions of mental disorders in the world health organization's world mental health survey initiative. world psychiatry psychological burden of quarantine in children and adolescents: a rapid systematic review and proposed solutions mental health effects of school closures during covid- psychological interventions during covid- : challenges for low and middle income countries mental health interventions in schools in low-income and middle-income countries school closure and management practices during coronavirus outbreaks including covid- : a rapid systematic review key: cord- -venpta authors: filgueiras, a.; stults-kolehmainen, m. title: factors linked to changes in mental health outcomes among brazilians in quarantine due to covid- date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: venpta the covid- pandemic is a crisis of global proportions with a significant impact on the country of brazil. the aims of this investigation were to track changes and risk factors for mental health outcomes during state-mandated quarantine. adults residing in brazil (n = , . years of age, . % female) were surveyed at the start of quarantine and month later. outcomes assessed included perceived stress, state anxiety and depression. aside from demographics, behaviors and attitudes assessed included exercise, diet, use of tele-psychotherapy and number of covid- related risk factors, such as perceived risk of covid- , information overload, and feeling imprisoned. overall, all mental health outcomes worsened from time to time , although there was a significant gender x time interaction for stress. . % of the sample reported stress above the clinical cut-off ( sd above mean), while . % and . % were above this cutoff for depression and anxiety, respectively. in repeated measures analysis, female gender, worsening diet and excess of covid- information was related to all mental health outcomes. changes in diet for the worse were associated with increases in anxiety. exercise frequency was clearly related to state anxiety ( days/week > days/week). those who did aerobic exercise did not have any increase in depression. use of tele-psychotherapy predicted lower levels of depression and anxiety. in multiple regression, anxiety was predicted by the greatest number of covid- specific factors. in conclusion, mental health outcomes worsened for brazilians during the first month of quarantine and these changes are associated with a variety of risk factors. the covid- pandemic is a crisis of global proportions with a significant impact on the country of brazil. the aims of this investigation were to track changes and risk factors for mental health outcomes during state-mandated quarantine. adults residing in brazil (n = , . years of age, . % female) were surveyed at the start of quarantine and month later. outcomes assessed included perceived stress, state anxiety and depression. aside from demographics, behaviors and attitudes assessed included exercise, diet, use of tele-psychotherapy and number of covid- related risk factors, such as perceived risk of covid- , information overload, and feeling imprisoned. overall, all mental health outcomes worsened from time to time , although there was a significant gender x time interaction for stress. . % of the sample reported stress above the clinical cut-off ( sd above mean), while . % and . % were above this cutoff for depression and anxiety, respectively. in repeated measures analysis, female gender, worsening diet and excess of covid- information was related to all mental health outcomes. changes in diet for the worse were associated with increases in anxiety. exercise frequency was clearly related to state anxiety ( days/week > days/week). those who did aerobic exercise did not have any increase in depression. use of tele-psychotherapy predicted lower levels of depression and anxiety. in multiple regression, anxiety was predicted by the greatest number of introduction mental health comprises the set of emotions, thoughts and behaviours that enable individuals to work, cope and deal with problems in everyday tasks (who, ) . historically, although researchers from the biomedical sciences dedicated more time and resources in the study of physical health, findings from the last years have slowly captured the interest of scientists from diverse fields to look upon mental health to explain somatic diseases, physical functioning, quality-of-life, well-being and work productivity, (christensen et al., ; prince et al., ; stults-kolehmainen, tuit & sinha, ) . for instance, mental health is associated with disability-adjusted life years (dalys) and premature mortality (vigo, kestel, pendakur et al., ) with % of dalys attributable to mental health in brazil and % in the united states. those with worse mental health, such as higher levels of chronic stress, have a greater risk for physical health problems, such as cardiovascular disease (stults-kolehmainen, ). poor mental health costs society a great deal of money, in terms of lost productivity, strain on healthcare systems, loss of income and other consequences (trautman, rehm, wittchen, ). on the other hand, recent research from the world health organization suggests that every one american-dollar spent in mental health care is equivalent to a return of four american-dollars in better well-being and ability to work (who, ).thus, a person who has good mental health entails someone who is physically healthy, happy and productive for themselves and the greater functioning of society (prince et al., ; who, ) . the recent outbreak of the corona virus disease (covid- or sars-cov- ) around the world at the end of and the beginning of led to a series of guidelines to avoid mass contamination and limit its lethality (who, ). among these recommendations are quarantine, confinement and social distancing (wilder-smith & freeman, ). these impositions mean that people cannot walk freely from their homes; they need to keep a -meter physical distance from one another on the streets and sick people are obliged to be confined in hospitals or their own homes without any kind of physical proximity to others. these restrictions are intended to benefit the physical health and safety of all people and must be adopted to save lives. unfortunately, such directives come at a cost to the mental health and well-being a substantial proportion of the population (rubin & wessely, is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . an updated systematic review on the effects of social distancing and quarantine on mental health revealed that anxiety, depression, stress, anger, insomnia, hopelessness, and sadness were all increased during those conditions (brooks et al., ) . a recent study (hu, su et al., ) from a cross-national sample (n = ) in china found that levels of anxiety increased, and . % of the population was anxious at clinically relevant levels. other behavioural problems also appear during this period; participants in a nationwide survey recently published in china reported nutritional issues, lack of ability to exercise and numerous changes in daily routines and habits (qiu et al., ) . accordingly, psychosocial and behavioural dimensions seem associated under quarantine conditions (filgueiras & stults-kolehmainen, unfortunately, resources are scarce in every field of the health system, including those for mental health (qiu et al., ) . therefore, it is pivotal to establish a priori where and how to invest those scarce resources. this is a difficult task because the current stressor is highly unique. quarantine is due to a pandemic of truly global proportions that has reached every level of society, with a long duration and remarkable social upheaval (who, ). there is no research on the association between psychological, demographic and behaviour variables in the general population during society-wide social isolation. furthermore, it is a consensus that psychological phenomena, such as stress and depression, are multifactorial with a large amount of variables to consider (who, ; ) . in order to help governments, service providers and scientists to . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) comparing before and during quarantine (options were "no changes"; "increased exercise frequency" and "decreased exercise frequency") and (xiii) types of exercise (aerobic, anaerobic, both, no exercise). it also collected data regarding diet and nutritional habits: (xiv) possible changes on diet by comparing before and during quarantine; whether the person (xv) gained or (xvi) lost more than kilograms since the beginning of the quarantine. finally, attitudinal questions were also computed. one question (xvii) asked about the amount of information the participant felt he/she was receiving and the answers were provided in three possible categories to choose from: "too much information", "enough information" and "little information". . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . another three items were informed in a five-point likert-type scale ranging from "totally agree" to "totally disagree"; the items were: (xviii) "do you feel imprisoned due to this quarantine?", (xix) "do you feel you are able to understand what is happening?", (xx) "do you trust your own ability to differentiate good from bad sources of information?". the pss- (cohen & williamson, ) is a -item questionnaire that asks individuals about their perception regarding stress-like symptoms. it is answered in a five-point likert-type scale ranging from "never" to "very often" (scores range from - ). the population mean is . (sd = . ) with a score over indicating excessive stress (cacciari, haddad, dalmas, ) . the fdi (filgueiras et al., ) is a -item scale that asks individuals to grade the level of association between the respondent's own self-perception and one-word items extracted from depression symptoms listed in the dsm-v in the last fortnight. it is rated in a six-point likert- type scale ranging from "not related to me at all" to "totally related to me" (scores range from - of the respondent who answers questions about own feelings in a four-point likert-type scale ranging from "not at all" to "very much so" (scores range from - ). gender-specific reference means are . (sd = . ) for men and . ( . ) for women, with cut-offs being for men and for women (pasquali, pinelli jr, soha, ) . volunteers of the present research answered the questionnaires in the google forms online platform that was configured in the same order of presentation: ) term of consent, ) demographic and attitudinal questionnaire, ) pss- , ) fdi, ) s-stai, ) thank you page. those participants who answered "no" to the term of consent were addressed to the thank you page without having any contact with the other questionnaires. first round of data collection (time ) took place between march th and march th , , whereas the second round (time ) happened between april th and april th , . after data collection, google spreadsheets were utilized to consolidate the database and to export it in the format .csv. then, researchers used spss (ibm, version . ) to run the analyses. descriptive statistics of pss- , fdi and s-stai were calculated for each categorical (demographic) variable with exception of those that were answered in likert-type scales. due to the large amount of variables collected in an online platform, cronbach's alpha (α) was calculated for the three scales in time and time ; results were expected to show α > . . pairwise t-test comparisons between groups were computed to identify significant differences between the first round (time ) and second round (time ) of data collection for the whole sample. a repeated-measures anova was performed to compare within and between groups for each demographic independent variable. furthermore, prevalence of stress, depression and anxiety-like symptoms were calculated in percentage of participants above the means and cut-off . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . for perceived stress, ( . %) and ( . %) of participants scored above the population mean at time and , respectively. prevalence of excessive stress (> sd above reference mean) was . % (ic . %- . %) in the first round and . % (ic . %- . %) in the second round. of the individuals in this category, % of these individuals were women. % did no exercise at all, but the remaining % complete days a week of exercise. also, % utilized tele-psychotherapy. regarding depression, ( . %) and ( . %) of participants were above the reference mean at time and , respectively. high depression (> sd above reference mean) had a prevalence of . % (ic . %- . %) at time and . % (ic . %- . %) at . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . time . participants > sd (n = ) were mostly women ( %) and did not utilized tele psychotherapy ( % as exercise frequency and perceived stress (r = -. ); whereas, moderate correlations were found between the same variable between time and time (intertemporal correlations). tables and supplemental provide the correlation matrix of the psychological variables. to understand what is happening, level of education and gender respectively. independent variables explained % of the variance of depression in the second round of data collection. finally, the state anxiety lmr depicted that the dependent variable (s-stai time ) was predicted, in order of association, risk for covid- , feeling safe, the score of s-stai time , weight loss, changes on diet, amount of information, feeling imprisoned and age. independent variables of this lmr explained cumulatively % of the variance. table presents the coefficient β , the t-test statistics, effect-size and coefficient of determination for the three lmr. the current investigation provides a unique glimpse into the mental health of brazilians in the midst of quarantine from the covid- pandemic, a novel, disruptive and society-wide stressor. findings indicate that a substantial portion of respondents were distressed at both time points, . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint with worsening mental health from the initiation of quarantine to a point one month later. more specifically, increases in perceived stress, depression and state anxiety were observed, with a gender x time interaction recorded for stress. men experienced increases in depression and anxiety over time, but not for perceived stress. across genders, the number of days in quarantine was linearly related to worse perceptions of perceived stress. repeated measures anova revealed that factors were all related to worse levels of stress, depression and anxiety: female gender, worsening diet and excess of covid- information. in regression analyses, however, mental health outcomes were influenced by a variety of other demographic, covid- specific, and behavioural factors, such as use of tele-psychotherapy. exercise-related factors, such as exercise frequency, were the predominate predictors of perceived stress. a substantial portion of the participants reported levels of stress, depression and anxiety above established means for the population. at time , greater than % of the sample was above the normative mean for both stress and depression. for anxiety, > % of both men and women were above the normative mean. more importantly, some participants scored very high for mental health disturbances, especially at time . for stress, . % of the sample was above sd at time , whereas the prevalence according to the brazilian norms is . % (cacciari, haddad & dalmas, ) . this was an increase from . % at time . similar trends were seen for depression ( . % at time , . % at time ; versus a norm of . %) (filgueiras et al., ) and state anxiety ( . % increasing to . %; versus a norm of . %) (pasquali, pinelli jr & solha, ) . this is similar to anxiety levels observed in a large sample during quarantine in china (hu, su et al., ) . while the percentage of individuals scoring at these extremes is still relatively low, it potentially represents a huge increase in burden to society when multiplied across the entire population. mental health initiatives on the national level would have to be scaled up to meet new demand (who, ) . key to this endeavour would be a) identifying those most at risk and b) properly assessing their condition. in the effort to identify those most at risk, pertinent predictors of mental health outcomes were analysed. interestingly, each mental health indicator was predicted by a varying set of factors. condition of regrets about the past (buechler, ) , was understandably not predicted by covid- related factors. only "understanding what is happening" was a significant inverse predictor. stress was predicted by feelings of being imprisoned, days in quarantine and risk for covid- and also by a number of exercise factors. in general, exercise was associated with mental health outcomes in the expected manner -more frequent exercise and aerobic exercise being related to the lowest levels of distress. for all . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . mental health outcomes, those with no exercise ( days per week) had the highest average levels of stress ( . at time to . at time ), depression ( . to . ) and anxiety ( . to . ). these seems to support the previous findings that "something is better than nothing" ( slightly different, with changes in exercise not being significant, but use of online fitness coaching reaching significance. an interaction was observed in that those who performed aerobic exercise had the lowest levels of depression at both time points. in fact, those who did aerobic exercise did not have any increase in depression. however, the clearest association of exercise frequency and mental health was for anxiety. those at the highest levels of exercise had the lowest anxiety and each day less was associated with more anxiety. aside from exercise, there were notable findings for dietary habits and use of tele- psychotherapy. those who rated their dietary habits as becoming worse also had the highest levels of stress, depression and anxiety. those with the highest levels of anxiety were those with worsening diet at the second time point (effect size for interaction was . ). those who used online nutrition services had lower levels of depression, but there was no difference for stress or anxiety. those who utilized online psychotherapy reported lower levels of depression and anxiety. while there is no income data to explain use of online resources, those using online resources were more educated. thus one might surmise that those from better off demographic groups are less affected partly because of greater access to resources. given the limited quantity of resources to mitigate mental health impairments during crises, such as pandemic and quarantine, it is crucial to identify the risk factors that may predispose individuals for worsening outcomes. despite the progress this study makes in tracking changes in mental health and identifying risk factors, the current research does demonstrate some limitations. first of all, there was no pre- quarantine baseline and assessments spanned just a single month. furthermore, this was a relatively well-off population with higher-educated individuals being over-represented in the sample. there was no measure of adherence to quarantine guidelines. it is possible that those with higher compliance to regulations could be of either higher or lower distress. to lessen . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . survey fatigue for participants, validated measures of exercise and dietary habits, which can be very lengthy, were not utilized. more importantly, the current data needs interpreted with some caution because factors other than quarantine could contribute to changes in the mental health outcomes observed, such as growing political and economic unrest in brazil (the lancet, ). also, it should be noted that effect sizes for changes over month were small (cohen's d were . -stress, . -depression, and . -anxiety), possibly because in some cases individuals had improved mental health (n = ; . %) due to quarantine conditions, such as being closer to loved ones throughout the day or being removed from dangerous work environments. lastly, correlations between instruments at time or time were small -possibly indicating the uniqueness of the quarantine as a stressor, particularly given the rapidly changing circumstances during this time period (main, zhou et al., ) . this study provides crucial data needed to understand how pandemic, state-mandated quarantine is related to changes in mental health outcomes. from the time point when quarantine was decreed until month later, worsening perceived stress, depression and anxiety was observed in this sample of the brazilian population. moreover, many individuals in the sample reported very high levels of distress (> sd). at the time of writing of this study, the quarantine is still being enforced and cases of covid- and associated deaths on rising rapidly (the lancet, ; imperial college covid- response team, ). future research should continue to track these trends as the crisis unfolds. analyses from this study identified several risk factors for mental health, including gender (being female), lower education, less exercise, worsening diet and a lack of resources, such as access to tele-psychotherapy. covid- related factors 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social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus ( - ncov) outbreak out of the shadows: making mental health a global development priority world bank group and world health organization promoting mental health: concepts, emerging evidence, practice (summary report). geneva: world health organization considerations for quarantine of individuals in the context of containment for coronavirus disease (covid- ): interim guidance the anxiolytic effects of exercise: a meta-analysis of randomized trials and dose-response analysis the present research is funded by the coordenacao de aperfeicoamento de pessoal de nivel superior (capes) of the ministry of education of brazil under the proap program. key: cord- - xjmv authors: aravena, j. m.; aceituno, c.; nyhan, k.; shi, k.; vermund, s.; levy, b. r. title: 'drawing on wisdom to cope with adversity:' a systematic review protocol of older adults' mental and psychosocial health during acute respiratory disease propagated-type epidemics and pandemics (covid- , sars-cov, mers, and influenza). date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: xjmv background: mental health has become one of the fundamental priorities during the covid- pandemic. situations like physical distancing as well as being constantly tagged as the most vulnerable group could expose older adults to mental and psychosocial burdens. nonetheless, there is little clarity about the impact of the covid- pandemic or similar pandemics in the past on the mental illness, wellbeing, and psychosocial health of the older population compared to other age groups. objectives: to describe the patterns of older adults' mental and psychosocial health related to acute respiratory disease propagated-type epidemics and pandemics and to evaluate the differences with how other age groups respond. eligibility criteria: quantitative and qualitative studies evaluating mental illness, wellbeing, or psychosocial health outcomes associated with respiratory propagated epidemics and pandemics exposure or periods (covid- , sars-cov, mers, and influenza) in people years or older. data source: original articles published until june st, , in any language searched in the electronic healthcare and social sciences database: medline, embase, cinahl, psycinfo, scopus, who global literature on coronavirus disease database, china national knowledge infrastructure ( - cnki). furthermore, eppi centre's covid- living systematic map and the publicly available publication list of the covid- living systematic review will be incorporated for preprints and recent covid- publications. data extraction: two independent reviewers will extract predefined parameters. the risk of bias will be assessed. data synthesis: data synthesis will be performed according to study type and design, type of epidemic and pandemic, types of outcomes (mental health and psychosocial outcomes), and participant characteristics (e.g., sex, race, age, socioeconomic status, food security, presence of dependency in daily life activities independent/dependent older adults). comparison between sex, race, and other age groups will be performed qualitatively, and quantitatively if enough data is available. the risk of bias and study heterogeneity will be reported for quantitative studies. conclusion: this study will provide information to take actions to address potential mental health difficulties during the covid- pandemic in older adults and to understand responses on this age group. furthermore, it will be useful to identify potential groups that are more vulnerable or resilient to the mental-health challenges of the current worldwide pandemic. according to the world health organization (who), mental health is defined as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community". this definition considers several aspects of wellbeing and psychosocial health that are fundamental to maintain an optimal state of health. on the other hand, a relevant part of mental health acknowledges the influence of mental illness in the life of people. mental illness is described by the american psychiatric association (apa) as "health conditions involving changes in emotion, thinking or behavior (or a combination of these). mental illnesses are associated with distress and/or problems functioning in social, work, or family activities." under both definitions, mental health will be influenced by psychosocial situations as well as mental illness. the presence of harmful psychosocial exposures (e.g., loneliness, stigma, social isolation) and an increase in mental illness can be triggered by exposure to natural disasters that affect populational health such as epidemics and pandemics. the recent sars-cov- virus (covid- ) outbreak has meant a major threat to the worldwide population in several aspects of health, including mental health and psychosocial health, being an emerging significant challenge and research priority for the global population. a good point of comparison to understand covid- present and future mental-health consequences are the past and present experiences observed during epidemics and pandemics outbreaks of similar characteristics. experiences observed in other acute respiratory infections-propagated epidemics and pandemics like sars-cov, mers, and influenza, have left us a precedent of information regarding its substantial impact on people's mental health. situations such as physical distance as one of the most critical measures, uncontrolled exposure to media news about the virus, spread biased or false information, quarantine, isolation, economic hardships, loss of love ones, health consequences, burden, stigma, fear, and anxiety; consequences that have been observed in the present and passed epidemic and pandemic scenarios. - therefore, these experiences must be carefully considered to generate an early response at an individual and populational level, and to anticipate prospective mental health scenarios. in that regard, recently rogers and cols have observed through a systematic review and meta-analysis of psychiatric and neuropsychiatric consequences associated with coronaviruses infections that among patients with severe sars or mers coronavirus infections, delirium, post-traumatic stress disorder, depression, anxiety, and fatigue are common. moreover, in some preliminary data, covid- would present delirium as well as confusion, agitation, depressive symptoms, anxiety, and insomnia. this study set an important precedent about how impactful the coronavirus infection in mental health could be. although, the study did not include the contextual impact of epidemic and pandemics, the full range of psychosocial and wellbeing aspects, and did not compare the mental health among different ages. areas that must be analyzed to understand the full range of influences in mental health and experiences across age groups. a group that could be highly affected are those who have been categorized as high-risk to present severe symptoms or mortality related to the virus such as people with chronic diseases and groups of older adults. covid- pandemic has demonstrated to be a critical challenge for older people's physical health. people years or older are the population with the highest risk of mortality associated with covid- worldwide. patients with multimorbidity and cardiovascular risk, which increase exponentially after years old, are particularly prone to manifest severe symptoms. [ ] [ ] [ ] thus, many communities have suggested or enforced particularly strict prevention measures for older persons with these characteristics. mental health burden could be an associated consequence of being the population at the highest risk and the exposure to strict social isolation in a pandemic. covid- virus and its preventive methods imply important mental health challenges for older people and caregiver's health that must be addressed on time. the classification of "population of high-risk" or in need of shielding could be a source of stress and stigma for older adults, incrementing its social isolation and mental illness symptoms such as anxiety or depression. , mental health burden is particularly harmful to older adults with some degree of dependence in daily life activities or multimorbidity because they manifest a higher risk to experience increased physical frailty and worsening of other diseases. [ ] [ ] [ ] [ ] [ ] if mental illness symptoms and psychosocial difficulties increase in the frail and geriatric older adult' populations during a pandemic period, the rise of dependency, chronic diseases, and emergency visits for causes other than covid- would be an enormous collateral impact of the current worldwide pandemic. diverse and often underlooked realities of aging constitute older adulthood, from independent older adults who have not stopped their work activity, caregivers of family members (e.g., other older adults, grandchildren), older people living on their own, or heads of household, to older persons who require the support of a third person, or others who live in long-term care institutions. in this context, older adults' mental health during natural disasters is controversial. some studies about resilience in other contexts have shown that older adults tend to report a higher resilience and more positive outcome than other age groups, , and others have estimated that older adults are . and . more likely to experience ptsd and adjustment disorder symptoms after natural disasters compared to younger adults, respectively. nevertheless, under normal circumstances, the evidence has shown that older people then to manifest greater levels of wellbeing, lower levels of negative affects, and less distress during their social interactions than other age groups. furthermore, studies have evidenced that older adults are more prone to put attention to positive stimulus than negative ones compared to younger people that present opposite patterns, putting more focus on negative situations. , this talks about certain ability to allocate emotional resources that could be fundamental to cope in a more positive manner with unpredictable or emotionally demanding events. despite all of these, there has not yet been a systematic evaluation to understand these patterns in the context of epidemics or pandemics. therefore, although older adults have been constantly classified as a vulnerable population for covid- , there exists uncertainty about how older adults, compared to other age groups, could respond to a situation that requires an important mental endurance like an epidemic or pandemic. published and ongoing studies, such as roger et al, who have characterized the mental illness and neuropsychiatric consequences associated to coronavirus infections in the general population, and qin and cols who have registered a protocol for a meta-analysis of the impact of covid- on the mental wellbeing of elderly population, have focused their reviews just on clinical outcomes related to mental health. in this context, and considering the increasing number of covid- related articles, a systematic review targeted to older people mental health considering a full-range of neuropsychiatric, psychiatric, psychosocial, and wellbeing parameters associated with the infection or the contextual impacts related to acute respiratory disease propagated-type epidemics and pandemics, contrasting the results among groups seems pertinent and necessary to fully understand the response and experiences of older adults and other age groups in the context of pandemics. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . to comprehend what could be the potential mental health impact associated with respiratory propagated epidemics and pandemics in older adults, and to evaluate the contrast among different age groups it is critical information for the development and planning of policies and programs to address these consequences early and to understand intergenerational differences and similarities in the mental health response to epidemic and pandemics. at the same time, it is fundamental information for the development of interventions and the implementation of policies targeted to change or promote behaviors related to compliance of nonpharmacological measures to prevent the spread of acute respiratory diseases during the context of epidemics and pandemics. considering this background, the main goal of this review is to describe the patterns of older adults' mental health related to acute respiratory disease propagated-type epidemics and pandemics. specifically, this systematic review aims ) to describe the associations between respiratory propagated epidemic and pandemics and older adult's mental health, ) to describe the differences between older adults and other age groups in the effects of mental health factors related to acute respiratory disease propagated-type epidemics and pandemics periods in the mental health, ) to assess the effect of interventions in the older adult's mental health associated to respiratory propagated epidemic and pandemics, and ) to consider moderators of the impact of pandemics on older adults' mental health. the report of the study will follow the prisma statement for reporting systematic reviews and metaanalyses guidelines. we will select studies that: ) describe the effects of acute respiratory disease propagated-type epidemics or pandemics on mental health or psychosocial parameters, and ) include older adults in the sample. quantitative, qualitative, and mixed-method studies will be included in order to consider different aspects of mental health and psychosocial impact. any study evaluating people years or older residing in any setting. research involving people from other age groups (e.g. children, adolescents, adults) additionally to people years or older will be included for analysis. for this review, studies conducted evaluating the impact on mental health during defined acute respiratory disease propagated-type epidemic or pandemic according to the infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care: who guidelines. : sars coronavirus (sars-cov), middle east respiratory syndrome (mers), and influenza/flu (h n , h n ). sars coronavirus (sars-cov- or covid- ) will be also included. these viruses are selected because they share similar epidemiological characteristics, where its pathogens can cause large scale outbreaks with high morbidity and mortality. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint for the purpose of this review, any study describing outcomes associated with mental health parameters in older adults will be included. mental health will be understood under the who definition: "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community." for practical operationalization, it will be divided into two main components: mental illness and psychosocial health/wellbeing. examples of mental illness parameters are depression, anxiety, and mood disorders, including intervention studies. studies analyzing parameters such as cognition, dementia, and delirium would be incorporated under the umbrella of mental illness aspects because people with these diagnoses frequently manifest neuropsychiatric symptoms. examples of psychosocial health/wellbeing factors are quality of life, stigma, isolation, and loneliness. studies evaluating the mental illness and psychosocial health/wellbeing parameters of caregivers of older adults will be incorporated. original articles published until june st, , in any language searched in the electronic healthcare and social sciences databases: medline (ovid), embase (ovid), cinahl (ebsco), psycinfo (ovid), scopus, who global literature on coronavirus disease database, china national knowledge infrastructure (中国知网 -cnki). because of limitations in database coverage and indexing speed, covid- related articles will be identified in two other ways. first, studies in the eppi centre covid- living systematic map of the evidence screening review which are tagged with "health impacts," "social/economic impact," or "mental health impacts" will be added to the screening workflow. the eppi centre covid- map consists of studies on covid- , identified in medline and embase, and published in or later. second, for better coverage of preprints, we will use the publicly available publication list of the covid- living systematic review , which retrieves articles from the preprints databases biorxiv and medrxiv and it is continuously updated. because more covid- related articles are published week by week, after the title-abstract screening is completed, another search exclusively for covid- related-articles will be performed in order to include manuscripts that potentially were published or indexed after the date of the first round of database searches. articles included from this second covid- related-articles extraction will be screened in the same fashion as the other studies. an example of the medline search strategy and a search source scheme are described in the supplement section. the search will be adjusted for appropriate controlled vocabulary and syntax in each database. in each database, the search has three elements: queries for the exposure of interest (covid- or other respiratory-propagated pandemics), the outcomes of interest (mental health), and the population of interest (older adults). controlled vocabulary and indexing status will be used, where possible, to maximize the retrieval of papers dealing with the older adult population and to minimize the burden of screening papers about other age groups. no specifications about the type of study are included in the search strategy to reduce the risk of missing studies. mental illness terms were included following the dsm-v and the cochrane common mental disorders group search strategies (https://cmd.cochrane.org/). some psychosocial health/wellbeing terms . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint were incorporated from other systematic reviews about psychosocial health and wellbeing and based on expert opinion. , because an important part of the epidemics and pandemics of these viruses has been experienced in the chinese population, culturally sensible terms to describe mental illness ('impulsive personality disorder,' 'qigong-induced disorders,' 'traveling psychosis,' 'shenjing shuairuo,' and 'neurasthenia') and psychosocial health/wellbeing conditions ('shame,' 'humiliation,' 'low spirits,' 'witchcraft,' 'curses,' 'zou huo ru mo -走火入魔-or qigong deviation -氣功偏差-') were included. , studies will be divided into two main categories for its analysis: ) studies describing the direct effect of virus infection on mental health outcomes, and ) studies illustrating mental health impact associated with the contextual situation of the epidemic or pandemic (e.g. quarantines, social distancing, isolation). the results from all the database searches will be collated in endnote and deduplicated by the cushing/whitney medical library cross-departmental team. the deduplicated results will be uploaded to covidence, an online platform for evidence synthesis. reviewers (ja and ca) will screen articles at the title abstract level, discarding only those articles which are evidently off-target. the full-text screening will also take place in covidence. two independent screeners will vote on each article; disagreements will be solved by consensus or third-party adjudication (bl). articles in english and spanish language will be manipulated by two reviewers (ja and ca). articles in other languages will be handled by two research members (ks and sv). two independent reviewers will perform data extraction using a prespecified data abstraction form designed for this study. the data abstraction form will be pilot-tested on five randomly-selected studies and refined accordingly. data extraction will include characteristics of the study (e.g. country, data source, data collection date, year), methods (e.g. study design, sample characteristics, outcome measurement), and results. extracted studies will be tagged according to the type of outcome they are describing: a) virus infection mental health-related outcomes, b) epidemic or pandemic context mental health-related outcomes, or c) both types of outcomes. data will be entered in a duplicated google questionnaire specifically designed for the study. every researcher will enter the data on independent questionnaires. qualitative and mixed-method studies will be described. quantitative studies will be included for assessment of the risk of bias. two reviewers will independently assess the internal validity of each included quantitative study. study risk of bias will be categorized as low risk of bias, some concerns of bias, and high risk of bias. in the case of observational studies, bias will be evaluated following the next standards: ) ttype of study design, ) temporality of the evaluation of the exposure: concordance in the evaluation timing of the impact of the epidemic/pandemic episode with the study goals, ) outcome evaluation: evaluation of the outcome with standardized and defined measurement instrument or methods, ) adjusted analysis: the . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . inclusion of an adjusted analysis of the main outcome considering relevant variables. for this review, analyses adjusting for age, sex, and pre-existing medical conditions or functional performance will be considered acceptable. ) attrition bias: for cohort studies, % of loss of follow-up will be considered as acceptable. for intervention studies evaluating efficacy or effectiveness in one or more mental health and psychosocial health as a primary outcome, the criteria to evaluate the risk of bias will be: ) type of study design, ) bias arising from the randomization process, ) bias due to deviations from intended interventions, ) bias due to missing outcome data, ) bias in measurement of the outcome, and ) bias in selection of the reported result. studies incorporating mental health parameters as secondary outcomes will be included for description yet will be considered at a high risk of bias. observational study's risk of bias was designed considering strobe and the ahrq methods guidelines. , intervention study risk of bias follows the cochrane handbook for systematic reviews. in the case of quantitative studies, for the continuous variables related to mental health, because of the variety of scores and outcomes produced by the diverse measurement scales, measures such as frequency and prevalence of symptoms and diagnosis (%) or adjusted prevalence, mean and standard deviation (sd) of total scores will be used. in comparison studies, mean differences (md), proportions (%), standardized mean differences (smd), b coefficient, and standardized error, with % confidence intervals (ci) for continuous outcomes will be included. dichotomous outcomes such as adjusted risk ratios (rr), odds ratio (or), and hazard ratio (hr) with % cis will be considered. unadjusted and adjusted results will be extracted. these measures will be extracted for people years older, other age groups described in every article, sex, and race if it is included. for treatment, in the case of cluster randomized trials or interventions delivered in groups, the unit of analysis will be the cluster. for interventions including individuals, the unit of analysis will be the subjects. in the case of rcts, we will seek data irrespective of compliance, in order to allow the intention to treat analysis. for cohort studies, we will make a qualitative evaluation of every study to identify if the missed data lead to a bias in the result. we will judge heterogeneity among studies (the type of study design, inclusion criteria, type of exposure/intervention, outcome measurement) during the qualitative synthesis of the data. additionally, statistical heterogeneity was evaluated using the i statistics, classifying no heterogeneity (< %), low ( - %), moderate ( - %), and high heterogeneity (equal or > %). we will decide on the appropriateness of conducting a meta-analysis based on qualitative and quantitative information. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . to avoid publication bias, we will search for published studies in multiple databases which include published journal articles and preprints. every study will be evaluated and discussed considering its bias and strengths for inclusion in the review. we will report the number of articles that do not fulfill requirements. for studies with two documents (preprint and journal publication), the official publication will be considered. in the studies with more than one analysis, the most tailored to our study aim publication will be considered. funnel plots will be performed for publication bias if we have enough data. a descriptive analysis of the included studies will be conducted through a flow diagram describing the number of included and excluded studies, exclusion reasons (e.g. older population not included, different epidemic/pandemic exposure, non-mental health outcomes), and the final number of selected studies. the results will be synthesized in tables and figures which may include the following. table will display study characteristics (country, data source, data collection dates, year, type of study/study design, total sample by group, follow-up, participants basic characteristics, exposed epidemic/pandemic), table outcome measurement (name of the outcomes, type of outcome -mental health/psychosocial-, outcome measurement, and results). a third table will describe intervention studies and its results (country, data collection and intervention delivery dates, year, type of research design, inclusion/exclusion criteria, description of the intervention, exposed epidemic/pandemic, sample by group, intervention/control characteristics, outcome measurement, results). data synthesis will be performed according to study type and design, type of epidemic and pandemic, types of outcomes (mental health and psychosocial outcomes), and participant characteristics (sex, race, comparison to other age groups, independent/dependent older adults). comparison between sex, race, and other age groups will be performed qualitatively, and quantitatively if the data available is enough. the risk of bias and heterogeneity will be reported for quantitative studies published in journal articles or preprints. if the available data is enough, we plan to conduct a subgroup analysis considering the following categories: type of study design, type of outcome measured, type of epidemic, or pandemic. if the data available is enough quantitative comparison of age groups will be conducted. we will perform a sensitivity analysis based on studies with a low risk of bias. mental health understood as a state of wellbeing has been a topic of special discussion and concern in the health and medical sciences because of its impact on the people's lives and the high burden for societies. in the context of large-scale natural disasters such as epidemics and pandemics, mental health would be highly determined by the manifestation of mental illnesses, neuropsychiatric conditions, and psychosocial aspects that will influence people's health and their capacity to cope with a mentally demanding . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . situation. this topic takes major relevance in the current scenario triggered by the covid- worldwide pandemic, where there exist and evident relevance of understanding the patterns of mental coping and adaptation of the global population. in our actual society, people years or older have been increasingly exposed to situations that are a threat to their mental health such as isolation and loneliness. at the same time, the constant exposure to 'ageism' or negative stereotypes associated with the aging as well as classifications of 'population of highrisk' or in need of shielding could be an important source of stress, fear, and segregation. nevertheless, even in the presence of these negative ideas about older people, the evidence has been uncertain about older adult's mental resilience and adaptation compared to other age groups in front of natural disasters. under normal situations, older adults have shown that they report higher general wellbeing and satisfaction with social connection than the younger groups. to our knowledge, this is the first systematic review evaluating the older adult's mental and psychosocial health compared to other age groups in the context of acute respiratory disease epidemics and pandemics. therefore, to understand how mental and psychosocial health could change during epidemics and pandemics of similar characteristics than covid- in older adults in contrast to other ages will be critical to elucidate the natural emergence of mental and behavioral coping mechanisms across life-stages, and to comprehend the major necessities referred by these groups. this information will be critical for the design of interventions and policies oriented to increment positive behavioral changes across age population groups and to promote the adherence to nonpharmacological preventive measures during epidemics and pandemics. promoting mental 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health implications for older adults after natural disasters--a systematic review and meta-analysis social and emotional aging aging and attentional biases for emotional faces unpleasant situations elicit different emotional responses in younger and older adults selective optimization with compensation a meta-analysis of the impact of covid- on the mental wellbeing of elderly population the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration systematic screening and assessment of psychosocial well-being and care needs of people with cancer. cochrane database syst rev eppi centre covid- : a living systematic map of the evidence screening review what is the impact on health and wellbeing of interventions that foster respect and social inclusion in community-residing older adults? a systematic review of quantitative and qualitative studies challenging mental health related stigma in china: systematic review and meta-analysis. i. interventions among the general public chinese classification of mental disorders (ccmd- ): towards integration in international classification the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies cochrane handbook for systematic reviews of interventions version available from www.training.cochrane.org/handbook social isolation and loneliness in older adults-a mental health/public health challenge key: cord- -q jbu r authors: alonso, j.; vilagut, g.; mortier, p.; ferrer, m.; alayo, i.; aragon-pena, a.; aragones, e.; campos, m.; del cura-gonzalez, i.; emparanza, j. i.; espuga, m.; forjaz, j.; gonzalez pinto, a.; haro, j. m.; lopez fresnena, n.; martinez de salazar, a.; molina, j. d.; orti lucas, r. m.; parellada, m.; pelayo-teran, j. m.; perez zapata, a.; pijoan, j. i.; plana, n.; puig, t.; rius, c.; rodriguez-blazquez, c.; sanz, f.; serra, c.; kessler, r. c.; bruffaerts, r.; vieta, e.; perez-sola, v.; group, mindcovid working title: mental health impact of the first wave of covid- pandemic on spanish healthcare workers: a large cross-sectional survey date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: q jbu r introduction: healthcare workers are vulnerable to adverse mental health impacts of covid- . we assessed prevalence of mental disorders and associated factors during the first wave of the pandemic among healthcare professionals in spain. methods: all workers in healthcare institutions ( aacc) in spain were invited to a series of online surveys assessing a wide range of individual characteristics, covid- infection status and exposure, and mental health status. here we report: current mental disorders (major depressive disorder-mdd- [phq- [≥] ], generalized anxiety disorder-gad- [gad- [≥] ], panic attacks, posttraumatic stress disorder -ptsd- [pcl- [≥] ]; and substance use disorder -sud-[cage-aid[≥] ]. severe disability assessed by the sheehan disability scale was used to identify "disabling" current mental disorders. results: , healthcare workers participated. prevalence of screen-positive disorder: . % mdd; . % gad, . % panic; . % ptsd; and . % sud. overall . % presented any current and . % any disabling current mental disorder. healthcare workers with prior lifetime mental disorders had almost twice the prevalence of current disorders than those without. adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (tus: or= . ; %ci . - . ; mood: or= . ; %ci: . - . ; anxiety: or= . ; %ci: . - . ); age category - years (or= . ; %ci: . - . ), caring "all of the time" for covid- patients (or= . ; %ci: . - . ), female gender (or= . ; %ci: . - . ) and having being in quarantine or isolated (or= . ; ci: . - . ). conclusions: current mental disorders were very frequent among spanish healthcare workers during the first wave of covid- . as the pandemic enters its second wave, careful monitoring and support is needed for healthcare workers, especially those with previous mental disorders and those caring covid- very often. covid- represents a major health challenge worldwide and several populations may experience adverse mental health related to the covid- pandemic , . among them, front-line healthcare workers are considered an extremely at risk population because of their direct exposure to infected patients, the limited availability of protective equipment, and the increased workload related to the pandemic. compared to the general community, healthcare workers have about times more risk for a positive covid- test . although with noticeable regional and international variations, it is estimated that - % of all covid- diagnoses occur in this population segment , . in addition to the risk of contagion and insufficiency of equipment and health services preparedness there is great concern for the potential impact (acute and longer term) on the mental health of healthcare workers. several systematic reviews and meta-analyses including studies on health care workers have documented that the first wave of the covid- was associated with an increase of symptoms of depression, anxiety, insomnia, and burnout, as well as other adverse psychosocial outcomes. luo et al , estimated that a quarter of healthcare workers suffered from anxiety ( %), depression ( %), and that about a third suffered substantial stress. similar figures were reported in other systematic reviews [ ] [ ] [ ] . in spain, a number of studies have been carried out to assess mental health of healthcare workers during the first wave of the covid- pandemic [ ] [ ] [ ] [ ] [ ] . in general, results are consistent with international data, showing high levels of anxiety, depression and stress symptoms. however, differences in study design, sample size as well as variation in the assessment and reporting of psychological impact and mental disorders hamper comparisons across studies. importantly, current studies have limited value when it comes to assessing the needs for care associated with the impact of covid- among healthcare workers. there is a necessity of credible and actionable indicators of mental disorders and their impact which more directly enable policy makers to allocate adequate resources when planning interventions. here we aimed to estimate the prevalence of clinically significant mental disorders among spanish healthcare professionals during the first wave of the covid- pandemic using a representative sample and well-validated screeners of common mental disorders. specifically, our objectives were to estimate ) prevalence of specific mental disorders, any such disorder, and any disabling disorder both in the total sample healthcare professionals and in subsamples of those with/without prior lifetime mental disorders; and ) associations of individual and professional characteristics, covid- infection status, and covid- exposure with these mental disorders. a multicenter, prospective, observational cohort study of spanish healthcare workers was carried out in a convenience sample of health care institutions from autonomous communities in spain (i.e., andalusia, the basque country, castile and leon, catalonia, madrid, and valencia). institutions were selected to reflect the geographical and sociodemographic variability in spain; all participating centers came from regions with high covid- caseloads. here we report on the baseline assessment of the cohort, which consists of de-identified web-based self-report surveys administered soon after the first covid- outbreak in spain (may -september , ). in each participating health care institution, institutional representatives invited all employed hospital workers to participate using the hospitals' administrative email distribution lists (i.e., census sampling). no further advertising of the survey was done and no incentives were offered for participation. the invitation email included an anonymous link to access the web-based survey platform (qualtrics.com). median survey response time was . minutes (iqr . - . ). informed consent was obtained from all participants at the first survey page. up to two reminder emails were sent within a - weeks period after the initial invitation. at the end of the survey, all participants were provided with a detailed list of local mental healthcare resources, including coordinates to nearby emergency care for respondents with a -day suicide attempt. participation was anonymous but participants could provide their email address at the end of the survey to participate in follow-up assessments of the cohort, which are conducted both at prespecified time points, and in function of the course of the pandemic. -major depressive disorder (mdd): evaluated with the patient health questionnaire (phq- ). we used the spanish version of the phq- (https://www.phqscreeners.com) with the cut-off point of or higher of the sum score to indicate current mdd. the phq- shows high reliability (> . ) and good diagnostic accuracy for major depressive disorder (auc> . ) . -generalized anxiety disorder (gad): evaluated with the seven-item generalized anxiety disorder scale (gad- ), which has a good performance to detect anxiety (auc> . ). we used the spanish version of the gad- (https://www.phqscreeners.com) and considered the cut-off point of or higher to indicate a current gad. -panic attacks: the number of panic attacks in the days prior to the interview was assessed with an item from the world mental health-international college student-wmh-ics . a dichotomous variable was created to indicate the presence of panic attacks. -posttraumatic stress disorder (ptsd): assessed using the -item version of the ptsd checklist for dsm- (pcl- ) [ ] [ ] which generates diagnoses that closely parallel those of the full pcl (auc> . ), making it well suited for screening . we used the spanish version of the questionnaire , and considered a cut-off point of to indicate current ptsd. -substance use disorder (sud): evaluated with the cage-aid questionnaire, that consists of items focusing on cutting down, annoyance by criticism, guilty feeling, and eye-openers. the all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; https://doi.org/ . / . . . doi: medrxiv preprint cage-aid has been proved useful in helping to make a diagnosis of alcoholism and substance use disorder . the questionnaire has been adapted into spanish. a cut-off point of was considered to indicate current sud . -disabling mental disorder: a mental disorder was considered "disabling" if the participant reported severe role impairment during the past months according to an adapted version of the sheehan disability scale , . a - visual analogue scale was used to rate the degree of impairment for four domains: home management/chores, work, close personal relationships, and social life. the scale was labeled as no interference ( ), mild ( - ), moderate ( - ), severe ( ) ( ) ( ) , and very severe ( ) interference. severe role impairment was defined as having a - rating [ ] [ ] [ ] . -prior lifetime mental disorders: lifetime mental disorders prior to the onset of the covid- outbreak were assessed using single-item screener variables based on the composite international diagnostic interview (cidi), including mood (i.e., depressive and bipolar disorders), anxiety (i.e., panic attacks, generalized anxiety and obsessive-compulsive disorders), substance use (i.e., alcohol, illicit drugs, and prescription drugs with or without prescription), and other disorders . we assessed the frequency of direct exposure to covid- infected patients during professional activity using one -level likert type item, ranging from "none of the time" to "all of the time. we defined frontline healthcare workers those reporting being exposed "all of the time" or "most of the time" to covid- patients. we assessed covid- infection status asking whether the respondent had been hospitalized for covid- infection and/or had a positive covid- test or medical diagnosis not requiring hospitalization. we also asked whether the respondent had been in isolation or quarantine because of exposure to covid- infected person(s), and whether s/he had close ones infected with covid- . we assessed: age; gender; country of birth; marital status; having children in care; living situation; and profession into categories: medical doctors, nurses, auxiliary nurses, other professions involved in patient care, and other professions not involved in patient care. the study complies with the principles established by national and international regulations, including the declaration of helsinki and the code of ethics. the data were pseudo-anonymized through encrypted identifiers, separating the personal information from the rest of the study data, to guarantee privacy and ensure de-identified treatment of the data in the analysis. the study protocol was approved by the irb parc de salut mar ( / /i) and by the corresponding irbs of all the participating centers. the study is registered at clinicaltrials.gov (https://clinicaltrials.gov/ct /show/nct ). analyses were restricted to the n = , respondents who completed all mental health items of the questionnaire. of them, an additional n = respondents were not included because they did not identify themselves with neither male nor female gender. in order to improve representativeness, observed data were weighted using raking procedure to reproduce marginal distributions of gender, age and professional category of healthcare personnel in each participating institution, as well as distribution of personnel across institutions. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; https://doi.org/ . / . . . doi: medrxiv preprint median proportion of missingness per variable was less than %. however, to optimize survey timings, the sheehan disability scale was assessed only in a random % of the sample. missing item-level data from the sheehan scale and from all other variables included in the analysis were handled using multiple imputation (mi) by chained equations with imputed datasets and iterations. these included all study variables and additional variables from the questionnaire as predictors in the imputation regression equations. pooled estimates from multiple imputations and mi-based standard errors taking into account within-imputation and between-imputation variances were obtained. distribution of individual characteristics and covid- infection and exposure variables were obtained for the whole sample as weighted percentage and standard error. prevalence estimates of specific current mental disorders, any current mental disorder, and any disabling disorder were estimated, overall and stratified by individual characteristics. chi-square tests from mi pooled using rubin's rule were used to determine significant differences across strata. adjustment for multiple comparisons was performed using the benjamini-hochberg procedure with a false discovery rate of %. bivariable associations between each individual characteristic and current mental disorders and severe mental disorder were estimated for the overall sample, and separately for individuals without a history of prior lifetime mental disorders (new onset), and for those reporting prior mental disorders (persistence/relapse). odds ratios (or) and mi-based % confidence intervals (cis) for each characteristic were calculated with logistic regression, adjusted by week of survey and health center membership. finally, multivariable associations between all covid- exposure and infection status, individual characteristics considered and current and disabling mental disorders were also estimated with logistic regression, stratifying by prior lifetime mental disorders. mi were carried out using package mice from r , . analyses were performed using r v . . and sas v . . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; https://doi.org/ . / . . . doi: medrxiv preprint a total of , healthcare workers participated in the surveys. the response rate is difficult to estimate given that the survey view rate (i.e., the proportion of hospital workers that opened the invitation email) is unknown, except for one hospital ( . %). the survey participation rate (i.e., those that agreed to participate divided by those that responded to the informed consent on the first survey page) was . %, and the survey completion rate (i.e., those that completed the survey among those that agreed to participate) was . %. when the denominator used to calculate the response rate is the total number of health care workers listed in the email distribution list or the total number of healthcare workers employed as provided by the hospital representatives, the survey response is . % (see supplementary table ). the first two columns of table show the size and weighted distribution of the sample studied. healthcare professionals were mostly female ( . %), the larger age group was - years ( . %), just over half were married ( . %), four out of ten were living with children ( . %), and . % were living in an apartment. about a fourth ( . %) were physicians, and . % were nurses, and the majority were working in a hospital ( . %). almost % of participants were directly involved in patient care, although less than a half ( . %) were directly exposed to covid- patients all or most of the time (i. e., frontline workers). almost a fifth ( . %) had covid- , . % had their spouse/couple, children or parents infected with covid- , and up to . % had been isolated or quarantined. an important proportion ( . %) reported a lifetime mental disorders before the pandemic. table , the prevalence of current mental disorders is presented according to the above variables. overall, . % met criteria for major depressive disorder, between . % and . % met criteria for anxiety disorders (gad, panic attacks, or ptsd), and . % met criteria for substance use disorder. in all, almost half of the sample ( . %) met criteria for current mental disorder and about one in seven ( . %) had a current disabling mental disorder. the prevalence of any current mental disorder was significantly higher among healthcare workers with female gender, younger age, not born in spain, not being married, or living with children less than years of age or not having children at home. auxiliary nurses and nurses showed the highest prevalence of current mental disorders ( . % and . %, respectively). there was a clear positive trend with higher exposure to covid- patients, and those having the disease --in particular those professionals who had been hospitalized for covid- , having been isolated or quarantined, and whose parents, children or partner were infected with covid- . prior lifetime mental disorders were strongly associated with presenting current mental disorder (especially those reporting previous substance use disorder or depression). the higher the number of prior lifetime mental disorders reported, the more likely the prevalence of any current disorder. similar prevalence differences were found when considering current disabling mental disorders. [ table , about here] all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; current mental disorders according to prior lifetime mental disorders: figure shows current prevalence of mental disorders according to pre-covid- pandemic lifetime mental disorders. prevalence was consistently lower among workers without prior mental disorders (new onset), i.e., approximately half than among workers with prior mental disorders (persistent/relapsing). [ figure , about here] figure shows current prevalence of any mental disorders (both disabling and non-disabling), according to pre-covid- pandemic prior lifetime mental disorders. among workers without prior mental disorders, the prevalence of any mental disorder (new onset) was almost % and one in four of those were disabling mental disorders (figure .a) . among healthcare workers with any prior lifetime disorder, the prevalence of current disorders (persistence/relapse) was much higher ( %), and more frequently disabling (i.e., one in three) (figure .b). [ figure , about here] factors associated with current mental disorders: table shows bivariate associations of individual characteristics, personal covid- exposure and prior lifetime mental disorders with any current mental disorder and with any current disabling mental disorder. the first two columns present the associations for the overall sample (n= , ) that had been presented in table in the form of odds ratios, once adjusting by week of the survey and by healthcare center. table also shows these associations, stratifying by prior lifetime mental disorders. columns - present data for those with no mental disorders prior to the covid- pandemic and columns - refer to those reporting mental disorders before the first wave of the covid- pandemic. in general, all the above-mentioned variables under study with any current (disabling) mental disorders were significantly associated with both new onset and persistence/relapse mental disorders. however, the association of hospitalization due to covid- with any current disabling disorder was only significant for those with previous mental disorders. among those with previous mental disorders, previous sud and previous depression were most strongly associated with current persisting/relapsing mental disorders. [ table , about here] table presents multivariable analyses of the associations described above, adjusting by all individual characteristics, covid- exposure factors, and healthcare center and week of interview. being female, and between ages - and being - were significantly associated with any and with any disabling current mental disorder. being a physician and a nurse was consistently associated with significantly lower odds of current mental disorders, while being an auxiliary nurse with previous mental disorders showed high (but not significant) ors of current disabling mental disorders. being a frontline healthcare worker was a very important risk factor of any current and any disabling disorder, as it was also having been in quarantine or isolated. the factors most strongly associated with current disabling mental disorders were previous substance use disorders, anxiety disorder and depression disorders. having more than one previous disorders was no longer statistically significant in the multivariate analysis. [ table , about here] all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. our results document a high prevalence of current mental disorders, with almost half of respondents screening positive on at least one of the five well-established screeners for common mental disorders. most important, in met criteria for a current disabling mental disorder. to the best of our knowledge, this is the first study to consider both symptom screening and disability as indicator of adverse mental health during the covid- pandemic. such a combination is potentially more valid and useful for services planning purposes, than descriptive information on psychological symptoms , . we also found that prevalence of adverse mental health was significantly more frequent among healthcare workers with prior mental disorders. finally, we found that being a female, having a high frequency of exposure to covid- patients, and having quarantined or isolated are risk factors for both any current disorder and any disabling disorder. the prevalence estimates found in our study of mdd ( . %) and gad ( . %) was well within the range of meta-analytic reports of healthcare workers studied in predominantly asian healthcare settings , [ ] [ ] . our estimated prevalence of ptsd ( . %) was also remarkably similar to that reported among healthcare workers in a meta-analysis ( . %) . substance use disorder was present in . % of our sample. only a few studies have reported empirical estimates of this disorder during the covid- pandemic and we were unable to find any specific data among healthcare workers. our results suggest that this disorder has a considerably lower prevalence than found in the general adult populations of the us and france . to the best of our knowledge, no previous report has presented data on the prevalence of any mental disorder and any disabling mental disorder among healthcare workers during the covid- pandemic. the prevalence in our study (i.e., . % of the responding healthcare workers meet criteria for any of the five assessed disorders) is somewhat higher than the . % of ≥ adverse mental or behavioral health symptom in the adult us population . more importantly, in presented a current disabling mental disorder, pointing to the high interference of adverse mental health on, professional, domestic, personal, and social activities. our results suggest that there are large mental healthcare needs to meet among healthcare professionals. there is need to closely monitor the extent to which these needs are adequately met. an important finding of our study is the strong association of prior lifetime disorders with any current disabling mental disorder (with odds ratios ranging from . to . ). this result, which is consistent with our clinical experience during the first wave of the pandemic, strongly suggests that healthcare workers with such a history must be considered a group at especially high risk. adequate mental health monitoring and support measures should be made accessible to this important group of healthcare workers. strengths of our study include the large number of institutions included and their spread over the most affected regions of spain; the use of the institutional mailing lists as the sampling framework, which provided specific and reliable listing of healthcare workers; data representative of a large number of healthcare workers; and the higher validity of screening of symptoms with severe interference to identify disabling mental disorders. these strengths support the robustness and relevance of our results. nevertheless, the study has some limitations that deserve careful consideration. first, we had a low response rate. despite important advantages of institutional email listings, these email accounts seem not to be checked by a large majority of employees and their utilization might differ by professional category. in fact, in our study we could assess the proportion of workers who read their first email invitation, which was less than %. in addition, invitations were limited to a maximum of due to institutional requirements. however, in order to improve representativeness, we have carefully weighted the observed data as to exactly reproduce the gender, age and professional category distribution of healthcare personnel in each participating institution. second, the study was cross-sectional in nature and it cannot be used to infer any causal impact of the covid- pandemic on the mental health of healthcare workers. nevertheless, we used clear and relevant recall periods to make sure the symptoms were present after the pandemic and had started for most of the symptoms, a short period before the interview. furthermore, we did collect information on mental disorders the respondents had suffered any time in their life before the covid- pandemic. third, measures used to assess mental disorders in our study are based on self-reports and not on clinical diagnoses. nevertheless, there is good evidence of acceptable sensitivity and specificity of the assessment for the current score cutoffs used here for current major depression disorder , generalized anxiety disorder and post-traumatic stress disorders . these measures are among the most frequently used in epidemiologic studies which allows comparability of results. for lifetime disorders we used a list of disorders which have been shown to have acceptable agreement with clinical evaluations . the high prevalence of both lifetime and current mental disorders found in our study suggests that a part might include false positive cases; and some of the real cases may have a mild disorder. it is for this reason that we propose to consider disabling current mental disorders a better estimate the needs for mental healthcare in this population , . healthcare workers with disabling current mental disorder in our study had much more frequent (between and three times more) mental comorbidity, current suicidal ideation, poor perceived (data not presented, available upon request). notwithstanding the limitations, our study shows a high prevalence of current mental disorders among spanish healthcare workers during the first wave of the covid- pandemic, with in presenting a disabling mental disorder. prevalence of adverse mental health was significantly more frequent among healthcare workers reporting lifetime mental disorders before the pandemic, which identifies a group in need of current monitoring and adequate support, especially as the pandemic is entering in its second wave. other healthcare workers that should be monitored include with a high frequency of exposure to covid- patients, who had been infected or have been quarantined or isolated, as well as female workers, auxiliary nurses and nurses. the authors would like to sincerely thank all healthcare workers that participated in the study in extremely busy times. they also thank very much puri barbas and franco amigo for the management of the project, and carme gasull for manuscript preparation and submission. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; table (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science covid- pandemic and mental health consequences: systematic review of the current evidence risk of covid- among front-line health-care workers and the general community: a prospective cohort study characteristics of health care personnel with covid- : united 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authors: drissi, nidal; ouhbi, sofia; janati idrissi, mohammed abdou; ghogho, mounir title: an analysis on self-management and treatment-related functionality and characteristics of highly rated anxiety apps date: - - journal: int j med inform doi: . /j.ijmedinf. . sha: doc_id: cord_uid: eqn kl p background and objective: anxiety is a common emotion that people often feel in certain situations. but when the feeling of anxiety is persistent and interferes with a person's day to day life then this may likely be an anxiety disorder. anxiety disorders are a common issue worldwide and can fall under general anxiety, panic attacks, and social anxiety among others. they can be disabling and can impact all aspects of an individual's life, including work, education, and personal relationships. it is important that people with anxiety receive appropriate care, which in some cases may prove difficult due to mental health care delivery barriers such as cost, stigma, or distance from mental health services. a potential solution to this could be mobile mental health applications. these can serve as effective and promising tools to assist in the management of anxiety and to overcome some of the aforementioned barriers. the objective of this study is to provide an analysis of treatment and management-related functionality and characteristics of high-rated mobile applications (apps) for anxiety, which are available for android and ios systems. method: a broad search was performed in the google play store and app store following the preferred reporting items for systematic reviews and meta-analysis (prisma) protocol to identify existing apps for anxiety. a set of free and highly rated apps for anxiety were identified and the selected apps were then installed and analyzed according to a predefined data extraction strategy. results: a total of anxiety apps were selected ( android apps and ios apps). besides anxiety, the selected apps addressed several health issues including stress, depression, sleep issues, and eating disorders. the apps adopted various treatment and management approaches such as meditation, breathing exercises, mindfulness and cognitive behavioral therapy. results also showed that % of the selected apps used various gamification features to motivate users to keep using them, % provided social features including chat, communication with others and links to sources of help; % offered offline availability; and only % reported involvement of mental health professionals in their design. conclusions: anxiety apps incorporate various mental health care management methods and approaches. apps can serve as promising tools to assist large numbers of people suffering from general anxiety or from anxiety disorders, anytime, anywhere, and particularly in the current covid- pandemic. education, and relationships [ , ] . the exact causes of anxiety disorders are still unknown. according to the national institute of mental health, it is likely to be a combination of genetic and environmental factors [ ] . other possible factors that can lead to susceptibility include brain chemistry, personality type, exposure to certain mental and/or physical disorders, trauma and stress [ ] . the covid- outbreak, in addition to being a public health emergency, is also affecting mental health in individuals on a global scale causing people to suffer from stress, anxiety, and depression [ , ] . the pandemic is also triggering feelings of fear, worry, sadness, and anger [ , ] . quarantines, self-isolation, fear of the unknown, loss of freedom and other factors are causing psychological issues in people around the world [ , ] . these situations and circumstances can trigger several anxiety disorders, mainly separation anxiety disorder which is defined as fear of being away from home or loved ones, illness anxiety disorder which is defined as anxiety about a person's health (formerly called hypochondria) [ ] and panic attacks that are affecting a large number of people because of excessive worrying. psychiatric patients are additionally at a higher risk of experiencing symptoms related to psychological issues caused by the pandemic [ ] . people with preexisting anxiety disorders are showing aggravation of their conditions, for example, many people with ocd are developing new fixations on the covid- virus and are experiencing compulsive cleaning [ ] . due to the covid- pandemic, social interactions have significantly decreased in several parts of the world. while this may have provided relief to some people with social anxiety, it is possible this lack of interaction may have negative consequences in the longer term [ ] . returning to work after a period of lockdown, while still in the state of pandemic, is also causing the workforce to exhibit symptoms related to ptsd, stress, anxiety, depression and insomnia [ ] . the current covid- situation is also affecting the mental well-being of health care workers, who are at a high risk of psychological distress [ ] , especially those who are experiencing physical symptoms [ ] . the situation is further worsened by the recommended avoidance of inperson contact and fear of infection, as people with anxiety and other mental disorders might not be able to consult with a mental health professional. there are various barriers to mental health care delivery, such as cost, stigma, lack of mental health care professionals, and distance from health care services [ , ] . mobile mental health or m-mental health, which uses mobile technologies for providing mental health services, has the potential to help overcome mental health care delivery barriers, as it provides anonymous access to care, low to no cost care, and remote communication. smartphones can be a convenient tool to reach a large number of people from different parts of the world. there are many mobile applications (apps) for mental health problems such as ptsd [ , ] , stress [ ] , depression [ ] and alcohol dependence [ ] , as well as other health issues such as obesity, that apps can help with, especially due to lack of exercise during circumstances similar to the current lockdown [ ] . smartphone apps have high rates of acceptance among the general public, and especially in young people [ ] due to its cost effectiveness [ ] . many studies have reported that apps have shown positive results in the treatment and management of anxiety [ , , ] . this study aims to analyze the functionality and characteristics of highly j o u r n a l p r e -p r o o f rated anxiety apps to identify users' preferred features and management methods delivered for anxiety with a smartphone or a tablet. for the purposes of this study, only free apps were selected, as recent statistics in march showed that . % of android apps and . % of ios apps were freely available worldwide [ ] . a total of apps, android apps, and ios apps were selected. the anxiety management approaches used in these apps among other aspects of functionality have been extracted and analyzed. this section presents the methodology that was followed in order to select and analyze android and ios anxiety apps. this paper follows the quality reporting guidelines set out by the preferred reporting items for systematic reviews and meta-analysis (prisma) group to ensure clarity and transparency of reporting [ ] . google play repository and the app store were used as sources to select anxiety apps. both app repositories are very popular with a high number of available health care apps: more than , apps are available in the google play store, and more than , apps are available in the app store [ ] . a general search string, composed of only one word "anxiety", was used. it was automatically applied to the titles and descriptions of android and ios apps. j o u r n a l p r e -p r o o f each app from the search result was examined by the first author to decide whether or not to be included in the final selection. the second author revised the final apps selection. the following inclusion criteria (ic) were applied: • ic : anxiety related apps in google play store and app store. • ic : apps that have a free version. • ic : apps that have + stars rating. ic reflects a level of user satisfaction with the app. the focus is on highly rated anxiety apps so as to discover the functionality features and characteristics that provide high user satisfaction. the following exclusion criteria (ec) were applied to the candidate apps to identify the final selection that would be included in this study: • ec : apps that have less than raters. • ec : apps that could not be installed. • ec : apps that crashed and could not be used after installation. apps that match any of the ec were excluded from the selection. ec is based on the heuristic guideline by nielsen [ ] , which recommends having five evaluators to form an idea about the problems related to usability. the apps' selection process was established as follows: . the search string was used to identify candidate apps in the google play store and app store in order to create a broad selection from which to choose from. . ic were used to identify relevant apps. . apps that met one or more of the ec were excluded. the above actions were carried out in march . a final selection of android apps and ios apps was identified after application of ic and ec. fig. presents the selection results. data collection was carried out using the data extraction form presented in table . each app was installed and assessed to explore its functionality features and characteristics. the devices used for the apps' assessment were: oppo a (android ), and ipad (ios ). a template was designed in an excel file to provide basic information about the apps as well as specifying their main features and functionality characteristics. some of these characteristics and functionality features were retrieved from the app's description available in the app repository. this section presents and discusses the results of this study. a total of apps, android apps, and ios apps were identified as both free and highly rated apps. tables a. , a. , a. , a. , a. and a. in appendix present general information about the apps such as name, link, rating, number of raters, number of installations (not available for ios apps), and date of latest update. the majority of the selected apps ( %) offer in-app purchases for paid features and functionality. these apps are free to download and use, but many of their proposed functionality features are not available without purchase. thus, it can be said that users may not fully benefit from the app unless they purchase these specific features. however, it should also be noted that in-app purchases are a way for many developers to monetize their work j o u r n a l p r e -p r o o f apps general information: -name of the app. -date of the latest update. -users rating (scored out of ): to report the level of user satisfaction from the apps. -number of raters: to report the number of raters satisfied with the app. -number of installations (not available for ios apps): to identify the most installed apps. -in-app purchase: to identify whether free apps charge users for certain functionality features. -management method: to identify management and treatment methods for anxiety that could be delivered through an app, and the most used ones in the available apps. -intervention approach: to identify approaches that could be transmitted through an app, and the most followed approaches in the available apps. -targeted mental problem/symptoms: to identify anxiety related issues addressed by the apps and issues that might be managed with similar management methods and approaches as ones for anxiety, as well as to identify problems that could be treated and managed through apps. -involvement of mental health care professional: this information was extracted from apps' descriptions in-app repositories and from apps' content. we consider mental health care professionals to be those professionals with a mental health background including psychiatrists, therapists, counselors and experts in psychological issues or management methods. -physical health information such as hr and bp: to identify whether the app relies on physical indicators to assess the mental status of the user. -authentication method: to identify if the app provides users with the option to keep their personal health data inaccessible to other users of the same device. -gamification features: to identify whether gamification features are included in the app to encourage and motivate the users to keep using it. -social features which might include: links to communities, associations, and centers; interoperability with other apps or websites; the possibility to share content via social networks (sn); and contact information in case of emergencies. -languages: identify the availability of the apps in multiple languages, which reflects the degree of internationalization of the app. -offline availability: identify whether the app can be used without internet access. [ ] . the free version of the app is used by many developers as an advertisement tool to attract users into purchasing and unlocking more features [ ] . free apps with in-app options are becoming the norm in-app markets. in , in-app purchases accounted for more than % of ios app revenue in the us and % of revenue in asia [ ] . the majority of the selected apps ( %) updated their functionality and content in the three first months of . this could be linked to the current covid- pandemic situation. on december st, the who china office was informed of a number of pneumonia cases from an unknown cause, that were later linked to the coronavirus [ ] , which has now spread to all regions of the world [ ] . to limit the spread and risk of the virus, the who advised the public to practice social distancing and to stay home [ ] . many countries have declared obligatory lockdowns and people were quarantined, which has created a state of fear and worry that has elevated many individuals' anxiety and stress. various existing anxiety apps have, thus, been updated to include covid- related content. table presents various management methods identified in the selected anxiety apps with meditation and breathing exercises being the most common. the main goal of meditation is to help the user enter a deep state of relaxation or a state of restful alertness. it helps to reduce worrying thoughts, which play a key role in symptoms of anxiety, and bring about a feeling of balance, calmness, and focus [ ] . several studies have presented evidence supporting the use of meditation in anxiety treatments [ , , ] . one study reported that it was beneficial for a group of chinese nursing students j o u r n a l p r e -p r o o f meditation a , a , a , a , a , a , a -a , a , a , a , a -a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , i , i , i -i , i , i , i , i , i , i , i , i , i , i , i , i breathing exercises a , a , a , a , a , a , a , a a , a , a , , i i i i games a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , i , i , i , i , i -i , i , i , i , i , i -i , i , i , i assessment tests a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , i , i stories a , a , a , a , a , a , a , a , a , i , i , i , i , i , i , i mindfulness practices a , a , a , a , a , a , a , a , i , i , i , i , i , i , i , i guided relaxation a , a , a , a , a , a , a , a , a , a , i , i , i , i community chats with app users via the app a , a , a , a , a , a , a , a , a , a ,i yoga and physical exercises a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , i motivational and inspirational statements a , a , a , a , a , a , a , a , a ,i , i , i online therapy and coaching a , a , a , a , a , a , a , a i , i recommending activities and tips a , a , a , a , a , a , a , a ,i interactive messaging a , a , a , a in reducing anxiety symptoms and lowering systolic bp [ ] . another study reported that it showed improvements in the reduction of anxiety for breast cancer patients [ ] . a meta-analysis of controlled trials for the use of meditation for anxiety also reported a level of efficacy of meditative therapies in reducing anxiety symptoms [ ] . additionally, meditation has been shown to be effective in managing various types of anxiety such as panic disorder and agoraphobia [ ] . breathing exercises are another mechanism that can help to relax and relieve stress. while practicing deep breathing, a message is sent to the brain to calm down and relax. biochemical changes subsequently decrease hr and bp and help the person to relax [ ] . studies have shown that breathing exercises can improve cognition and overall well-being [ ] , while also reducing anxiety [ , , , , ] . breathing exercises can also have a positive impact on psychological distress, quality of sleep [ ] , depression [ , , ] , everyday stress, ptsd, and stress-related medical illnesses [ , ] . breathing exercises are also used to help with asthma, which was the case in a and a . however, it should be noted that such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication [ ] . many of the selected apps provided educational content about anxiety and other mental issues, symptoms, and management methods, either in the form of courses, articles, videos, or others. educating users about anxiety can help to reassure them and provide them with the necessary knowledge by answering questions and correcting misinformation that they might have. educating users about the provided management method and its benefits may also increase their trust in the management approach and their willingness to try it. mental assessment tests have been provided by some apps to give the user an idea about his/her mental status, anxiety, stress and/or depression levels. relaxing music and sounds, is a noninvasive and free of side-effects ap-proach that has been used in apps as a management method. it has been shown to be an effective tool for the reduction of anxiety, stress, and depression [ , ] . it has also shown positive results in the prevention of anxiety and stress-induced changes like hr and bp [ ] . developers should take into account the type of music and sounds used, as well as the accompanying environment, as they both affect the effectiveness of this method [ , ] . thirty-one apps provided journaling and writing diaries to help users plan their day, track their mood, and express their thoughts, feelings, and emotions. securing the privacy and confidentiality of users' information is critical in such apps. all selected ios apps providing journaling provide authentication methods, while only % of android apps with this functionality provide users with the same level of authentication. eleven apps provide the user with the possibility of communicating with other users. in these apps, users are able to share their experiences, talk about their issues, help each other, and relate to others who are undergoing similar problems as their own. in the current covid- pandemic, being in a state of isolation but having the ability to connect with an online community can be very helpful. the idea of enabling interaction with a community of people with similar issues is quite interesting and can be extremely helpful, especially given that people with anxiety often tend to avoid direct communication [ ] . for users who prefer communication with mental health care professionals, there are ten apps available that provide online therapy and coaching, enabling users to communicate with mental health care professionals, without having to travel, while also avoiding obstacles like stigma and distance. selected apps offering online therapy services charge fees for these services. these apps also provide information on the mental health care professionals' credentials. this information is important as it allows the user to check whether these professionals are appropriately accredited and decide which mental health care professional is most suited for his/her needs. thirty-three apps provide users with games like coloring books, puzzles, and slime simulations, as management methods for anxiety. these games help the user to relax, and to take his/her mind off worrying thoughts or feelings. games are usually enjoyable and entertaining and this may motivate users to continue using these apps. the variety of management methods identified in the selected apps points to the high potential of apps usage for coping with anxiety. developers have integrated various promising and effective management methods in their apps' functionality features. users can access these features at any time and in any place. this could be beneficial for users with anxiety disorders, especially in situations where immediate help is needed (e.g., during panic attacks), or in cases where mental health care professional cannot be reached due to circumstances like distance or the current global lockdown situation. table presents the selected apps which state the use of specific intervention approaches for anxiety management. the most used ones included mindfulness, cognitive behavioral therapy (cbt), and hypnosis. mindfulness was the most adopted management approach. it is defined as "bringing one's complete attention to the present experience on a moment-tomoment basis" [ ] . mindfulness practices allow practitioners to shift their concentration to their internal experiences occurring in each moment, such as anxiety and mood problems [ , ] , and improving an individual's internal cognitive, emotional, and physical experience [ ] . some findings suggest that mindfulness can be more complicated than it might seem, as many el-ements like attention emotional balance, differences in emotion-responding variables, and clinical context can influence its effect [ , , ] . therefore, these elements should be taken into account while developing mindfulnessbased anxiety apps. cbt is a form of psychological treatment, mainly based on efforts to change thinking patterns [ ] . many studies have supported the effectiveness of cbt-based interventions for the treatment of anxiety, and have reported on the long-term positive effect it has on both children and adults [ , ] . a study examining available evidence on cbt have yielded positive results and confirmed its effectiveness for anxiety disorders [ ] . cbt has also been used in the treatment of some specific anxiety disorders like ptsd [ ] and ocd [ ] . it has also been proved effective for depression, alcohol and drug use problems, eating disorders, and severe mental illness [ ] . cbt and mindfulness-based therapy can also be useful in reducing anxiety during the covid- pandemic [ ] . hypnosis is a therapeutic technique designed to bring relaxation and focus to the mind [ ] . many studies have reported the effectiveness of hypnosis for the treatment of anxiety. one study stated that it can reduce anxiety among palliative care patients with cancer [ ] , and another reported on its considerable benefits to terminally ill patients [ ] . hypnosis is also used to treat and manage stress and phobias [ ] , as well as sleep and physical symptoms [ ] . other approaches have also been identified in the selected apps as shown in table , but it should be noted that a few of them were not based on scientific approaches. table presents the different health issues besides anxiety that were addressed by the selected apps. all selected apps addressed general anxiety. some apps addressed specific types of anxiety like social anxiety, separation anxiety, performance anxiety, ocd, ptsd, and panic attacks. focus and concentration a , a , a , a , a , a , a , i , i , i self-esteem and confidence a , a , a , a , a , a , a , i , i , i , i , i pain a , a , a , a , a , a , a , i , i mood a , a , a , a , a , a , a , a , a some apps addressed other mental and physical issues, which usually occur with anxiety like stress [ , ] , sleep issues [ ] , and depression [ , , ] . some apps used management methods to treat addiction-related issues, eating disorders [ ] , phobias, [ ] , and asthma [ ] . the majority of the apps do not use physical health information. hr and bp are impacted by anxiety and stress [ ] . both can be used by apps to indicate the anxiety level of the user [ ] . yet in our selection only two apps provided this functionality feature (a and a ). a collects data on hr variability, using the photoplethysmogram (ppg) technique to get insights on the user's health, including stress, energy, and productivity levels. the app also allows the user to manually enter bp as a convenient way of journaling. it should be noted that a provides cardiovascular tests, including hr and peripheral blood circulation, as an app purchase option. only % of the selected apps reported involvement of mental health care professionals as presented in table . apps providing online therapy specified information about the therapists that the user can contact. this information includes their specialty, experience, and diplomas. some apps shown in table provided names of the professionals involved in their co-creation. providing names gives the user the possibility to look online for the credentials of the involved professionals and might increase the user's trust toward these apps. we cross-checked the names displayed in table and found them to be legitimate. table table presents the authentication methods identified in the selected apps. the majority of the selected apps ( %) do not require authentication. the absence of authentication might give the user a sense of anonymity. however, authentication can help the user ensure the privacy of his/her data. the app a requests a nickname and a password, ensuring security and confidentiality as well as keeping the anonymity of the user, since it does not use any information or sources that could reveal the identity of the user like facebook account, google account, or email. nickname and password a gamification is the use of game elements in non-gaming systems which are mainly used to improve user experience and user engagement [ ] . table presents the different gamification methods identified in the selected apps. note that some apps use more than one gamification method. the majority of the selected apps used gamification features to encourage and motivate the user. creating a fun, interactive user experience with the adoption of game elements can create an enjoyable user experience, which can further reduce boredom and motivate users keep using the app. this can also increase user engagement, leading to users providing more accurate information about their mental health status and to increased benefit for the user from the provided mental health care management method. gamification is a widely used approach that has shown effectiveness with anxiety and other mental health problems, such as depression and ptsd for military personnel [ , ] , and aggression for veterans [ ] . combining j o u r n a l p r e -p r o o f game a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , a , i , i , i , i -i , i , i , i , i , i -i , i , i , i graphics a , a , a , a , a , a , a , a , a , a , a , a , a unlocking new features a , a , i , i , i score and points a , a , a , i stickers, awards and stars a , a , a , a , i game elements and knowledge on game players' behaviors with known mental health care management methods is an interesting approach that can result in the creation of effective anxiety apps. table presents the different social features provided by the selected apps. many apps provide social and communication features, which allow the user to connect with communities of app users as well as with centers and associations, or with others to share content and progress. those social features could prove to be beneficial to the user. for instance, sharing progress and content from the app via social networks (sn) and emails helps provide social support to the user from family and friends. social support is significantly associated with well-being and absence of psychological distress [ ] . it has a favorable effect on certain psychological issues [ ] , and can serve as a mediator to stress and anxiety caused by life events [ ] . providing social support is also among the behavioral change techniques implemented in m-health apps to promote app usage [ ] . additionally, providing contacts in case of emergencies is crucial and might help the user in critical situations j o u r n a l p r e -p r o o f where he/she feels the need for immediate help. links to associations, websites, and centers can provide the user with more helpful resources. social features are very important as they help the user connect with others in a beneficial way. emergency contacts' information a , a , a , a , a , a , a , a , a group treatment i , i table presents the languages available in the selected apps. the majority of the apps ( app) are available only in english, which can be explained by the fact that the search string applied in app repositories was in english. only one app (a ) automatically translates its content to the device's preferred language. while the rest of the apps are available in more than one language. availability in multiple languages can help reach a larger number of users. i , i -i , i , i , i , i , i , i , i , i -i , i -i , i , i , i -i more than one language a , a , a , a , a , a -a , a , a , a , a , a , a -a , a , a , a , a , a , a , a , i , i , i , i , i , i -i , i , i , i , i , i , i system's languages a j o u r n a l p r e -p r o o f table shows whether an app requires internet access to function or not. internet access is required to install and create accounts for all apps, but once that is done, many apps function without internet access. offline availability is an aspect that will help users benefit from the app without necessarily being in a setting with internet access. this will decrease the app's limitations and make it more accessible to users. however, some of the management methods identified do require internet access, like online therapy and communication with communities of app users. additionally, offline availability may require downloading more data that could be permanently stored, which may affect a phone's memory and performance. some apps were only partially available offline, resulting in limited functionality when internet access was not available. other apps only made downloaded data available offline, meaning the user chooses and downloads content that he/she wants to be available while offline. these are convenient solutions to offline availability that do not compromise on app functionality. this study is subject to limitations, such as: (i) missing terms (e.g., stress, depression) in the search string that might have resulted in the selection of relevant apps, as usually an app targets more than one mental health issue. however, the search string used identified any app that mentions anxiety in its title and/or description, therefore this can alleviate the threat of missing relevant apps; and (ii) the first author conducted the search and applied the ec and ic to the initial selection. however, the final selection has been reviewed by the second author. with the current development in mobile communication and the wide ownership of mobile devices, m-mental health seems to be one of the most promising ways to deliver care to people in need regardless of their situation. under certain circumstances like the current covid- pandemic, the use of mobile communication and apps for anxiety might become a necessity. panic attacks can mimic covid- symptoms, which might worsen the condition of people with anxiety disorders [ ] . having an app on hand that can ease anxiety in such circumstances is useful. this study highlights the functionality and characteristics of anxiety apps that are well rated by users. we plan to build on the reported findings to develop a reusable requirements catalog for anxiety apps. mental health care professionals and people with anxiety disorders will be involved in the co-creation of this catalog. the catalog will also include software quality requirements based on the iso/iec standard and recommendations from the uk national health service (nhs) and the health insurance portability and accountability act (hipaa) on health apps. since the reusable requirements catalog for anxiety apps will be based on functionality of existing highly rated apps, as well-being based on inputs from mental health care professionals and people suffering from anxiety, it could be used to assist developers to select relevant requirements for anxiety apps. apps could therefore be designed based on the catalog to assist people dealing with anxiety. requirements from the catalog could also be used to generate checklists for audit and evaluation purposes [ ] , either to evaluate apps or to compare their functionality and characteristics. the findings from this study may also assist researchers and developers interested in the field of m-mental health, especially in the sub-field of anxiety, to have an overview of the characteristics and functionality of existing highly rated apps for anxiety. our findings could also assist mental health professionals to find anxiety apps that could be integrated in their mental health care process, as well as assist people suffering from anxiety to find mobile apps best suited for their needs. during the covid- pandemic, mhealth can also help disseminate health information among health personnel and community workers [ ] . all authors contributed to the creation of the manuscript. nd: design, conception, acquisition and interpretation of data, classification of selected apps, drafting of the manuscript, revision. so: design, conception, statisti- j o u r n a l p r e -p r o o f what was already known on the topic: -anxiety disorders are a common mental issue. -there are many barriers to mental health care delivery, mainly cost, stigma and distance from health professionals. -apps were found to be effective tools to deliver mental health care, and overcome the aforementioned barriers. what this study added to our knowledge: - free and high-rated anxiety apps were analysed: android apps, and ios apps. -anxiety apps addressed other health issues, such as: stress, depression, sleep issues, and eating disorders. -anxiety apps adopted various management, treatment and coping approaches such as, meditation, breathing exercises, mindfulness and cognitive behavioral therapy. cal support, interpretation of data, drafting of the manuscript, critical revision. maji and mg: critical revision. all authors read and approved this manuscript. the authors have no conflict of interest. this article does not contain any studies with human participants or animals. j o u r n a l p r e -p r o o f what to know about 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military-related posttraumatic stress disorder virtual reality and cognitivebehavioral therapy for driving anxiety and aggression in veterans: a pilot study social support and mental health in community samples effects of social support and personal coping resources on depressive symptoms: different for various chronic diseases? social network mediation of anxiety behavior change techniques in top-ranked mobile apps for physical activity popular science. a panic attack can mimic the symptoms of covid- . here's what to do about it e-health internationalization requirements for audit purposes coverage of health information by different sources in communities: implication for covid- epidemic response deep key: cord- -lwbddab authors: antiporta, d. a.; bruni, a. title: emerging mental health challenges, strategies and opportunities in the context of the covid- pandemic: perspectives from south american decision-makers. date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: lwbddab background mental health awareness has increased during the covid- pandemic. although international guidelines address the mental health and psychosocial support (mhpss) response to emergencies, regional recommendations on covid- are still insufficient. we identified emerging mental health problems, strategies to address them, and opportunities to reform mental health systems during the covid- pandemic in south america. methods an anonymous online questionnaire was sent to mental health decision-makers of ministries of health in south american countries in mid-april . the semi-structured questionnaire had questions clustered into main sections: emerging challenges in mental health, current and potential strategies to face the pandemic, and, key elements for mental health reform. we identified keywords and themes for each section through summative content analysis. findings an increasing mental health burden and emerging needs are arising as direct and indirect consequences of the pandemic among health care providers and the general population. national lockdowns challenge the delivery and access to mental health treatment and care. strategies to meet these health needs rely heavily on timely and adequate responses by strengthened mental health governance and systems, availability of services, virtual platforms, and appropriate capacity building for service providers. short- and medium-term strategies focused on bolstering community-based mental health networks and telemedicine for high-risk populations. opportunities for long-term mental health reform entail strengthening legal frameworks, redistribution of financial resources and collaboration with local and international partners. interpretation mental health and psychosocial support have been identified as a priority area by south american countries in the covid- response. the pandemic has generated specific needs that require appropriate actions including: implementing virtual based interventions, orienting capacity building towards protection of users and health providers, strengthening evidence-driven decision making and integrating mhpss in high-level mechanisms guiding the response to covid- . funding none. the covid- pandemic has affected mental health and wellbeing as well as its determinants. general population have reported anxiety and stress while health professionals fear, and bereavement. mental health services have also been overburdened as the health needs increase as consequence of the pandemic and the isolation measures in place. the who general director has recognized mental health and psychological support (mhpps) as a major pillar in the overall health response to the covid- pandemic. likewise, the inter agency standing committee (iasc) published a global briefing recommending eight mhpps interventions to be implement during the crisis. nonetheless, evidence to guide action at regional and sub-regional levels is still insufficient. this study provides expert perspectives of decision-makers about mental health burden and actions during the covid- in south america, currently the most serious hub of infection worldwide. health services have reported an increase of anxiety, stress and fear among the general population emerging during the pandemic. the pandemic has generated specific needs that require appropriate actions including implementing virtual based interventions, bolstering community-based mental health networks, and integrating mhpss in high-level mechanisms guiding the response to covid- . decision-makers identified opportunities to seize for long-term mental health reform such as strengthening legal frameworks, redistribution of financial resources and collaboration with local and international partners. the importance of this research goes beyond documenting the status quo of mental health at country level, but implies fostering, enhancing and expanding collaborations in the sub-region to strengthen the mental health response to the covid- pandemic. country-cooperation initiatives in mental health have been an important strategy to improve local mental health systems and services. our findings are expected to better orient next steps in making decisions on mental health policies and services in south america, but also to inform public health key leaders and mental health experts within and beyond the region of the americas. mental health and psychosocial problems are expected to rise during adversity and crisis ( ) , such as the covid- pandemic ( ) , but awareness of mental health has already increased in media and academic platforms ( ) . general population have reported anxiety and stress ( , ) while health professionals and frontline aid workers reported fear and bereavement ( ) . isolation measures, discontinuity in health services, and scarce availability of medications represent additional barriers to preserving a good mental health. mental health and psychosocial support (mhpss) have been recognized as major components within the overall health response to the covid- pandemic ( ). mhpss include strategies to protect or promote psychological well-being and prevent mental conditions. the inter agency standing committee (iasc) has provided guidelines to address mental health and psychosocial aspects during the epidemic ( ) . while the iasc provides guidance on a global level, evidence to guide action at regional and sub-regional levels is still insufficient. region and country-based research can help reduce the evidence-gap on local mental health action and strategies. historically mental health care has been severely under-resourced; however, some regions like south america have made substantial progress regarding national policies and legal frameworks. for instance, peru initiated a radical mental health reform in that produced a shift from a hospital-centered mental health towards a community-based model ( ) . in paraguay was identified as the only country in the region of the americas to participate in the who mental health special initiative, which aims to ensure universal health coverage for mental health ( ) . the sars-cov- virus has spread widely in south america with , , confirmed cases and , deaths as of june th , ( ). recent forecasting models suggest a dramatic scenario for the coming . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint months projecting substantial increase in cases and deaths by august( ), despite wide lockdowns and curfews implemented in several countries. while many south american countries are fiercely fighting against the spread of the virus, additional challenges, for example increased mental health needs, have arisen amidst this pandemic. key responses in mental health entail a deeper understanding of local needs and interventions as well as identification of opportunities to strengthen mental health care. the relevance of this study lies in the need to generate evidence on the radical changes and emerging challenges created by the covid- pandemic. we gathered information from decision makers on the main needs in terms of mental health and wellbeing in south america. we identified emerging mental health challenges and strategies to reduce the negative impact of the epidemics, and, key opportunities to reform mental health systems and services by seizing opportunities during the crisis. we identified mental health focal points in ministries of health in all countries that belong to the pan american health organization (paho) south american subregion: argentina, bolivia, brazil, chile, colombia, chile, paraguay, peru, uruguay, and venezuela. electronic invitations were sent by email to at least one focal point per country between the april - , . eligible participants were ) at least years old, and, ) holding a high-level managerial position within their mental health directions or units. an anonymous online questionnaire was designed in qualtrics (provo, ut) about mental health in the context of the covid- pandemic. the questionnaire (see table ) had country-specific questions, divided in three sections: ) emerging challenges in mental health, ) current and potential strategies . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint (short-term, next two months, and medium-term, next six months, to face the pandemic, and, ) strategies and opportunities for mental health reform. the questionnaire had a semi-structured format and was designed to last around minutes to complete. following ethical principles, all participants voluntarily consented to participate in this questionnaire. the protocol and questionnaire were submitted to the johns hopkins bloomberg school of public health and the paho ethics review committee and all procedures were exempted for review. a qualitative approach was used performing summative content and thematic analysis. the research team first read the raw data of questionnaires and generated an initial codebook. the codebook and themes were revised and updated based on gaps shown by the initial list. early versions of findings were jointly reviewed by the team to agree on interpretability of results. analytical products are themes and keywords by each section. we used the software atlas.ti for windows to facilitate the data management and organization. for this study, we have used the following terms considering the local context and the purposes of the study. we have used the terms lockdown, quarantine, and home-stay policies interchangeably. while most participants referred to home-stay policies or lockdowns, they used the term "quarantine" in all cases to describe these policies. by stress reactions, we intended to capture all mental and psychosocial conditions and reactions that require 'any type of support that aims to protect or promote psychosocial wellbeing and/or prevent or treat mental disorder( ). this included keywords such as stress, post-traumatic stress, acute stress, and severe stress. lastly, we used anxiety to describe terms such as anxiety disorders and anguish. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . there was no funding source for this study. the corresponding author and first author had full access to all the data and had final responsibility for the decision to submit for publication. we received back out of complete questionnaires representing countries, and % of respondents were female. the median time for completion was minutes (iqr= min). all respondents worked in high ranked decision-making positions in mental health units, programs, or departments in their ministry of health of their respective countries. informants reported up to different emerging problems across countries. the most frequent mental health and psychosocial reactions reported were anxiety ( mentions), stress ( mentions), and fear ( mentions). reactions were attributed not only to the pandemic itself but also to public health measures that countries implemented to control the disease, such as total lockdowns and home-stay policies. another common topic was domestic violence affecting children and women. less frequent problems included insomnia, irritability, solitude, and sadness, especially among those who are living alone. informants were asked to rank the top different emerging problems based on the urgency to intervene. anxiety or anxiety disorders were ranked top across informants, although few also indicated stress reactions and fear. the second highest problem was not equally homogenous across informants, and answers ranged from an increase in consumption of substances, to stress reactions and depression. the third top priority was heterogenous and included domestic violence, substance use and impulsive reactions. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint participants indicated several challenges for mental health care delivery arising during the covid- pandemic, for which the identification of high-risk populations is necessary to plan appropriate responses. prioritized target populations include service providers, patients who were already in contact with the mental health services and potential new users that might need mental health support as a result of the pandemic, including those people that lost a relative or a loved one. the focus on health providers should not be limited to emergency room (er) and intensive care unit (icu) health professionals but should include mental health professionals as well. challenges that referred to the services offered were grouped into outpatient services, inpatient care, and availability of medications. outpatient services challenges included the limited capacity of health services to use virtual/telemedicine platforms to provide care to specific populations, i.e., elderly people, and indigenous communities, or to disseminate key messages and relevant information through mass media. challenges for inpatient care concerned adequate time for admissions and care provided during the lockdown. disruption in availability of psychotropic medications was described in terms of reduced access and distribution to inpatient and outpatient care facilities. other challenges related to organizational interventions and training for health providers. participants referred to the need for an action plan to strengthen community based mental health services and bridge the mental health treatment gap. they also referred to the need for synergies with public institutions and civil society to strengthen public mental health surveillance, interventions, and communication. additional challenges were the limited availability of virtual platforms and limited time for training service providers on adequate responses of mental health care, such as psychological first aid. the challenge that ranked highest was to maintain or reopen primary mental health care services to adequately respond to the needs of affected people and overcome the limitations of providing mhpss . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint interventions during the lockdown. other topics included the training of mental health providers, distribution of medications and caring for mental health providers. the second highest challenge was heterogeneous across participants: some referred to caring for the mental health and wellbeing of frontline workers, and adequate functioning of inpatient care. challenges ranked as the highest third referred to establishing or strengthening intersectoral work and providing psychosocial support to people and families affected by covid- . the main reported barriers for accessing mental health services, including therapies and other types of care, are the national lockdown measures, which have shut down most primary health centers to stop spreading the disease. scarce resources to reorganize mental health services to virtual forms and systems for appointments were also described as challenges that jeopardize access to services. the delivery of virtual-based treatments and interventions relies on the availability of services as well as patient's expertise to use technological tools, which are not optimal during the current scenario. access to care is also reduced due to the limited number of professional and functioning community centers with mental health care available during the pandemic. access to medications was also reported as a potential challenge given the lower availability of psychotropic medications as compared to those used in general health and for conditions related to the covid- . the highest ranked challenge was the continuity of care using strategies that respect the lockdown measures and providing appropriate care for patients. another topic that ranked highly was the limited availability of trained mental health providers in the primary care level. as second top challenges, participants described limited access to psychotropic medications during the pandemic as well as the lack of training and resources to implement telemedicine sessions. the third top challenge mentioned by participants was reaching out to vulnerable populations, such as those with low income. another topic . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint was the activation of emergency services for mental health to respond to increased demand during this crisis. strategies that have been implemented frequently during this time included the use of mass communication media, at national and local levels by ministries of health and community health centers. communications were tailored by life course stage or ethnicity in some countries. ongoing efforts aim to promote self-help mechanisms through social networks, at the national, regional, and municipal level. other strategies included establishing or strengthening mental health services through telemedicine and national or local hotlines for mental health care and psychosocial support. some countries reported hotlines for specific populations such as the elderly or people with disabilities. additional use of virtual platforms was referred by some respondents to implement mental health training, the exchange of experiences between territories and reporting to stakeholders from the national and local levels. a common short-term strategy was to ensure the adequate mental care of admitted persons, their families, and health providers at psychiatric hospitals as well of those in the highest risk units (i.e. er and icu). special attention was given to those patients who might need to be admitted in a context of limited availability of beds. psychosocial support was considered a crucial strategy to prevent stress reactions due to burnout and other consequences of the pandemic among health providers. access to pharmacological treatment was also a concern during the early stages. some strategies proposed to bridge the gap included the establishment of a virtual delivery system and partnerships with existing pharmaceutical networks to facilitate the access to these treatments. communication strategies for psychosocial education and support considering cultural and gender perspectives were also suggested. examples of the latter is the digital system of mental health care for health providers in chile. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint for the medium-term, strong relevance was given to the creation and use of virtual platforms and applications for delivery of mental health services, strengthening of social networks and offering psychosocial support. a mobile application in colombia that aims to screen for covid- symptoms, was cited as an example of an app that can provide mental health care information to a wider population. the need for a community-based mental health system, which strengthens the capacities of non-specialized primary health providers, was a recurrent topic among respondents. participants also mentioned the elaboration or strengthening of protocols and programs to provide care to people positive for covid- , specific populations, through the adequate implementation of the mental health gap action programme (mhgap) in the areas most affected by the crisis. participants also referred to the need for mental health professionals to be included in the multidisciplinary team that provides care to people affected by covid- . the increased awareness of mental health by stakeholders, media, and the general population, during the pandemic and the lockdowns, represents an opportunity to increase visibility of mental health, to mobilize resources and to prioritize mental health policies and interventions. communication strategies through social media and official channels can highlight the importance of mental health by offering self-help messages to manage stress and other reactions during the lockdown period. training health care providers in mental health strategies can increase awareness among these professionals. effective advocacy and leadership need to focus on strengthening mental health planning and legislation to adequately respond to the pandemic. the creation and inclusion of commissions for mental health within technical working groups will allow mental health services to be prioritized not only in the current response but also in the post-pandemic scenario. partnerships with local organizations and civil society are key to enhance the role of mental health response during the crisis. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint reorienting mental health services towards a community-based system will provide appropriate care tailored to the needs of the population. moreover, building information systems using timely and robust data will allow the monitoring of mental health burden and associated factors, to better inform stakeholders. when asked about opportunities to mobilize additional financial resources for mental health, respondents had few suggestions based on their country experience. some suggested redirecting resources from more specialized facilities towards the primary health networks or community-based centers. effective collaborations with local and regional authorities might facilitate the implementation of current mental health policies and lead to allocation of additional funds. international partners, such as cooperation bodies, were considered as potential sources of financial support and collaboration for articulated efforts in mental health care during the pandemic. the most cited institutions were paho/who ( / respondents) and unicef ( / respondents). on average, each participant reported at least institutions. an emerging burden of mental health needs is arising as direct and indirect consequences of the pandemic among the general population as well as health care providers in south america. national lockdowns and social distancing measures challenge the delivery and access of mental health care and treatment. strategies to meet these health needs heavily rely on timely and adequate responses by strengthened mental health governance and systems, availability of services and virtual platforms and appropriate capacity building for service providers. short-and medium-term strategies focus on the implementation of community-based mental health systems, virtual support, communications, and appropriate care for populations in vulnerable or high-risk settings. opportunities for long-term mental . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . health reform entail strengthening legal frameworks, redistribution of financial resources and collaboration with local and international partners. situations of emergencies normally translates into higher prevalence of mental conditions, including stress reactions, common and severe mental disorders ( , ) . participants reported a higher burden of anxiety and stress in their respective countries. other reactions can be also expected in severe covid- infections such as fatigue, delirium, and neuropsychiatric syndromes ( ) . detrimental effects in mental health have been reported in the general population ( , ) , health providers ( ) ( ) ( ) as well as overburdening health services ( ) . the novel cohabitation circumstance, consequence of lockdowns and home-stay policies, may represent an opportunity for exchange among family members and loved ones, but at the same time may result in increased tensions ( , ) and violence( ), including violence against women and children. home confinement has increased the prevalence of depressive symptoms among children ( ) . people with mental health disorders and disabilities may suffer further disruption in services and accommodation prior to covid- ( ) . increased consumption of alcohol and psychotropic substances will turn a difficult situation into a more challenging scenario. mental health plays a pivotal role in this context since it has plenty to contribute to improving positive coping mechanisms to face new challenges and hardships participants emphasized the relevance of ensuring the continuity of services. the capacity to adjust to the increased volume of people in need largely depends on the previous mental health infrastructure. importantly, health systems with well-developed community-based mental health networks are more likely to adjust to the novel scenario. conversely, health systems that are centered in acute care hospitals and psychiatric hospitals will struggle to respond to the increasing needs of the population and the preexisting mental health treatment gap may become more dramatic. the ministry of health of peru, for instance, is taking measures to ensure the community-based mental health centers keep functioning in a . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . where they implemented surveys, mental health education and psychological counselling services though online services ( ) . in colombia, a smartphone application was launched to provide support to covid- affected populations; this application includes a component entirely dedicated to mental health that orient users and provides them with appropriate information( ). maintaining a limited proportion of face-to-face interventions seems to be crucial, provided that sufficient protective measures are always taken to protect service users and health professionals. those settings where community-based services are more developed will be better positioned also to reorient the methods of delivering services and 'go virtual'. situations of crisis, such as the covid- pandemic, despite its inherent disruptive dramatic consequences, may generate important opportunities for improving mental health services( ). all respondents in our study presented their insights in seizing potential opportunities to reform mental health services in a long-term perspective. given the special nature of covid- and its profound impact on mental health and wellbeing of populations, this long-term approach seems fundamental in providing insights to decision makers beyond the most immediate response to the critical event. this study identified decision makers in high rank positions of mental health units at ministries of health as key informants during the early stage of the pandemic in south america. besides sharing their expert . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . opinion, this group was instrumental in identifying specific strategies to operationalize recommendations. despite participants being high-ranking officials, the survey was directed to a limited number of individuals. thus, the authors acknowledge the need for generating additional evidence and further investigate the perspectives of relevant key actors, including: senior mental health professionals, such as psychiatrists and psychiatric nurses, but also representatives from civil society such as service users and their family members or caregivers. we gathered information from all countries except for brazil, the biggest and most affected country by covid- pandemic in the subregion( ), due to administration changes during the time of data collection. nevertheless, our aim was to portray a sub-regional situation in mental health challenges and not country-specific profiles, for which collecting information from decision-makers of out of countries allowed us to fulfill the objective. mental health and psychosocial support have been identified as a priority area by south american countries in the covid- response. the pandemic has generated specific needs that require appropriate actions including: implementing virtual based interventions, orienting capacity building towards protection of users and health providers, strengthening evidence-driven decision making and integrating mhpss in high-level mechanisms guiding the response to covid- . the results of this study are expected to better orient next steps in making decisions on mental health policies and services in south america, but also to inform public health key leaders and mental health experts within and beyond the region of the americas. world health organization & united nations high commissioner for refugees. assessing mental health and psychosocial needs and resources: toolkit for humanitarian settings the mental health consequences of covid- and physical distancing: the need for prevention and early intervention the lancet p. mental health and covid- : change the conversation stress, anxiety, and depression levels in the initial stage of the covid- outbreak in a population sample in the northern spain covid- and mental health: a review of the existing literature -ncov epidemic: address mental health care to empower society addressing mental health needs: an integral part of covid- response interim briefing note addressing mental health and psychosocial aspects of covid- outbreak peruvian mental health reform: a framework for scaling-up mental health services world health organization. the who special initiative for mental health ( - ): universal health coverage for mental health. geneva: world health organization, . . pan american health organization (paho). cumulative covid- cases boadle a. who says the americas are new covid- epicenter as deaths surge in latin america. reuters improving mental health care in humanitarian emergencies psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid- pandemic mental health outcomes among frontline and second-line health care workers during the coronavirus disease (covid- ) pandemic in italy prioritizing physician mental health as covid- marches on mental health care for medical staff in china during the covid- outbreak mental health in the coronavirus disease emergency-the italian response mental health at the age of coronavirus: time for change. soc psychiatry psychiatr epidemiol mental health status among children in home confinement during the coronavirus disease patients with mental health disorders in the covid- epidemic online mental health services in china during the covid- outbreak. the lancet psychiatry the authors acknowledge the participants of this study, their disposition to contribute to our research and the mental health responses they are leading in their countries. potential and current strategies to reduce the negative impact of the epidemics on mental health and wellbeing . .what key strategies are being implemented to specifically address the mental health and wellbeing needs affected by the epidemic? what innovative actions and interventions would you consider for implementation in the short-term response? what innovative actions and interventions would you consider for implementation in the medium-term response? key elements to reform mental health systems and services seizing opportunities during the crisis. despite their tragic nature, and notwithstanding the human suffering they create, emergency situations are also opportunities to build better mental health care. what strategies should be adopted for prioritize mental health in the political agenda? what opportunities have you identify to mobilize additional financial resources? who are the international partners that you identify to support and strength mental health services? key: cord- -kjuc nqa authors: asiamah, nestor; opuni, frank frimpong; mends-brew, edwin; mensah, samuel worlanyo; mensah, henry kofi; quansah, fidelis title: short-term changes in behaviors resulting from covid- -related social isolation and their influences on mental health in ghana date: - - journal: community ment health j doi: . /s - - - sha: doc_id: cord_uid: kjuc nqa this study assessed the behavioral outcomes of coronavirus (covid- ) social distancing protocols and their influences on mental health. an online survey hosted by survey monkey was utilized to collect data from residents of three ghanaian cities of accra, kumasi and tamale. a total of surveys were analyzed, with a sensitivity analysis utilized to select covariates for the regression model. the average age of participants was about years. findings indicate that reduced physical activity time and a change in sexual activity and smoking frequency are some short-term changes in behavior resulting from social isolation during the lockdown. an increase in sedentary behavior had a negative influence on mental health. for the most part, changes in behaviors in the short-term were associated with lower mental health scores. the study implied that covid- social distancing measures should be implemented alongside public education for discouraging unhealthy changes in behaviors. coronavirus (covid- ) is a novel virus that was first detected in wuhan city, china (lewnard and lo ; lin et al. ) . over a period of < months (between december and april ), the virus grew from being a local epidemic in wuhan to a fear-inspiring global pandemic. as of september , , the virus had killed , out of , , people who tested positive for it (johns hopkins university ), making it one of the world's deadliest pandemics (lin et al. ; pung et al. ) . covid- can be considered a highly contagious virus not only because it has infected thousands of people but also because it has taken a relatively short time to spread to most regions of the world. without appropriate measures to contain it therefore, covid- could infect a third of the world in a year. as the case has been with previous pandemics, the nonavailability of a vaccine has allowed covid- to spread and grow into a global pandemic. since the testing and production of a potential vaccine for an infectious disease takes an average period of months (josefsberg and buckland ; anderson et al. ) , measures to cut the chains of infection are the only way to contain covid- in the short-term. one of such measures, which is considered the best way to contain an epidemic or pandemic in the absence of a vaccine (lin et al. ; pung et al. ) , is the enforcement of social distancing protocols in affected regions. with covid- , the adoption of this approach is a global shared goal that has brought about a complete or partial lockdown of affected countries. as demonstrated by china with its lockdown of wuhan, social distancing protocols are the ultimate weapon for fighting covid- in the short-term. this notwithstanding, their socio-economic impacts can be dire (brooks et al. ; armitage and nellums ) . economic impacts such as unemployment, the weakening of the foundation of the global economy characterized by the united states (us) and china, and a potential collapse of emerging economies, at least in the short-term, are frequently reported economic consequences of covid- (anderson et al. ; lewnard and lo ) . other consequences that are significant but seem underreported (lewnard and lo ; armitage and nellums ) are social implications such as public health decline that exacerbate the above economic losses. social distancing mechanisms, for example, could curtail individual physical activity (pa) trajectories. it is also possible that social distancing will limit access to food and public services, especially in developing countries where citizens may be unable to afford basic needs such as food if socially isolated. we argue based on the fogg behavior model (fbm) proposed by fogg ( ) that a pandemic such as covid- and its sudden lockdowns are extreme events that would cause fear and panic as people try to cope with them. per the disengagement theory of aging developed by cumming and henry ( ) , anxiety and mental health struggles may result from a sudden lockdown because social disengagement is a gradual process that would overwhelm people who try to achieve it instantly or in the short-term. we are, therefore, of the view that social isolation necessitated by a covid- -related lockdown would not only cause fear and panic in the short-term but could also lead to anxiety and consequently a decline in mental health in the general population. similarly, short-term social isolation can cause major changes in health behaviors that can increase the burden of disease and disability. this argument is corroborated by some researchers (malcolm et al. ; armitage and nellums ) who have opined that a decline in mental health is the most likely consequence of social isolation caused by an unexpected event such as the outbreak of a disease. if so, stakeholders need to understand how significant changes in behaviors and their influences on mental health are and roll out suitable programs for avoiding or at least reducing public health risks that could be predicted by a covid- lockdown. with some predicting the outbreak of a similar epidemic in future (lewnard and lo ; li and siegrist ) and others seeing the possibility of covid- spreading for a long time (li and siegrist ; pung et al. ) , stakeholders need to understand changes in behaviors that could result from a lockdown as a precursor to designing appropriate programs for discouraging unhealthy changes in behaviors. possible covid- -related changes in behaviors have been acknowledged in the literature. the most frequently acknowledged changes are reduced pa and increased sedentary behavior due to limited access to the built environment and community services during the lockdown ). on the other hand, the ability of exercise service providers to promptly move exercise classes online in response to social distancing measures have been reported jakobsson et al. ). as such, many individuals could exercise at home during the lockdown. conspiracy theories have also indicated that alcohol intake, smoking, and the use of some substances (e.g. garlic) can protect the individual against covid- . particularly in less educated populations, therefore, many individuals may take to substance use and smoking. because families including couples may spend more time together at home during the lockdown (fisher et al. ) , sexual activity and domestic violence are also likely to increase due to social distancing measures. this study aimed to examine these changes and their influences on mental health. we understand that the aforesaid changes can be affected by demographic and individual characteristics. education and income, for example, are likely to affect one's ability to utilize online exercise classes during the lockdown. for this reason, we adjusted for key covariates in testing the association between the said behavioral changes and mental health. our choice of mental health as an outcome variable draws on commentaries indicating that mental health is the aspect of health most likely to be affected in the short-term by social distancing protocols (serafini et al. ; vindegaard and eriksen benros ) . our investigation was based on this primary research question: do changes in behaviors due to covid- social distancing measures have a significant influence on mental health? this study employed the descriptive correlational approach and online surveys targeting the general population. a cross-sectional analysis technique was adopted. the exclusive use of an online survey was the only way to collect data during the lockdown. as this study was aimed at informing policy decisions for a specific region, the setting of this study was three cities (i.e. greater accra, kumasi, and tamale) affected by a covid- mandatory lockdown in ghana. the study population was individuals of the general population, preferably those aged years or more, who were socially isolated as they complied with the mandatory lockdown. participants were selected based on four inclusion criteria: ( ) currently living in any of the cities facing mandatory lockdown; ( ) having acquired at least a basic education instructed in english, the medium in which the survey was administered; ( ) being in social isolation owing to the lockdown; and ( ) willingness to participate in the study. the use of a powered sample (i.e. a sample determined based on a pre-determined statistical power and effect size) was not possible in this study for a couple of reasons. firstly, we did not find any existing study that was based on our context. secondly, we could not have used information from previous research to calculate a sample size because all existing studies applied substantially different methods. a deep look into the literature suggested that related webbased studies had utilized sample sizes ranging between n = and n = to reach credible findings (merolli et al. ; balhara and verma ; liang et al. ) . considering our research approach and the geographical scope of the study setting, we hoped to achieve a sample size between and . the survey was developed by the researchers and hosted on survey monkey, a free survey creation platform that allows data sharing and analysis between research team members. it was chosen because of the researchers' ample experience with it and the fact that it provides user-friendly data transfer and analysis tools. the survey was developed from scratch, as opposed to using a template, because no existing template was suited for our study. the survey comprised multiple-choice questions and a question introducing the mental health measure. the first question included the ethics statement and instructions for completing the survey. the next two questions (i.e. q and q ) screened for individuals who did not meet the inclusion criteria. questions - and captured demographic variables and covariates. changes in behaviors were measured with questions - as well as - . question presented the -item mental scale measure. the 'one question per page' design option that comes with the most legible text (regmi et al. ) was chosen. the survey was developed after the researchers discussed with two groups on what could be the ideal measures of mental health and changes in behaviors in the context of the study. the first group, which included four of the authors, was a whatsapp-based group made up of research fellows of a center of excellence. members, through the use of text messages and audio recordings, suggested potential measures for the study. over skype, the researchers then consulted with the second group, comprising two psychometricians and a statistician, to agree on an initial list of items for the survey. the lead researcher then developed a questionnaire of the items proposed. following this, copies of the questionnaire in sealed envelopes were sent through a private courier to individuals aged years or more who had agreed to complete it in the neighborhood of the lead researcher. this step was part of the survey piloting arrangement. over days, questionnaires were completed and returned by out of the participants through the courier. respondents commented on ambiguities and wording problems associated with the questionnaire. through a voice call, the lead researcher contacted the participants to confirm and better understand the issues reported, enabling the researchers to further improve the wording of the items. a major change made to the instrument was replacing the word 'self-isolation' with 'social isolation' in most of the measures. an online survey of the final items (including an ethics statement) was then developed and piloted online with different participants (whatsapp = ; facebook = ; twitter = ). with no issues identified in the second pilot study, we sent the survey back to the two psychometricians consulted earlier for approval. this study focused on possible short-term changes in behaviors resulting from covid- -related social isolation or fears. changes in smoking frequency, alcohol intake, and substance dependence were incorporated into the study owing to fake news about the possibility of smoking and the dependence on some substances (e.g. garlic, alcohol, marijuana) protecting against covid- . the other changes in behaviors were considered because they could be encouraged by social isolation. table shows a summary of all changes in behaviors and their operationalization. as table indicates, categorical variables were dummy-coded and one of their levels (categories) set as the reference. the table also shows underlying health conditions and demographic variables that, per existing studies (sederer ; lund et al. ) , can confound the primary relationships of interest. mental health was measured with a -item standard scale (with descriptive anchors strongly disagree- ; disagree- ; the individual's gross monthly income continuous --somewhat agree- ; agree- ; and strongly agree- ) from lukat et al. ( ) . this tool is a unidimensional scale that produced satisfactory psychometric properties (including a cronbach's α coefficient = . ) on a sample representing the general population. it was preferred to other mental health measures because it has been properly validated for the general population and is the most holistic mental health measure (lukat et al. ). in the current study, it produced a satisfactory cronbach's α coefficient of . . scores on the mental health measure were generated in harmony with the lukat and colleagues; items were 'parceled' by adding them up. appendix table shows items of the mental health measure used. this study received ethical clearance from an institutional ethics review committee (# -ace) after the research protocol and ethical statement were reviewed by the committee. in agreement with best practices, we ensured that the first question of the survey presented the ethical statement (merolli et al. ; balhara and verma ) , which means that only individuals who agreed to participate voluntarily (by ticking 'yes') completed the survey. the ethical statement indicated the purpose and importance of the study as well as the risk-free nature of our data collection process. the inclusion criteria and instructions for completing the survey were also presented as aspects of the ethical statement. we created different versions of the survey that could easily be completed on all social media platforms including whatsapp. we published the survey a week after the lockdown by sending a link of it to all our contacts using whatsapp and asking them to complete the questionnaire and share it with their contacts. thus, snowball selection was applied to distribute the survey. subsequently, the researchers, through their personal accounts, published the link on facebook, twitter, linkedin and other social media platforms. the shared link took the participant to a pop-up questionnaire that could be completed even with a relatively weak internet network. participants did not have to download the survey before completing it. the survey was distributed and completed over about weeks (april - , ) and was closed on april , . its average completion time was about min. we programed the survey at survey monkey to prevent multiple responses from the same participant. for further research purposes, we designed the survey to allow individuals outside the study setting to respond. we did not provide incentives for participation. data in a microsoft (ms) excel format were downloaded from survey monkey. coding was done in ms excel and the resulting data transported to spss version (ibm inc., ny, usa), which was used for data analysis. descriptive statistics (frequency and per cent) were used to summarize the data after five questionnaires with missing items were discarded in line with the recommendation of garson ( ) . the shapiro-wilk's test was performed to screen for outliers and confirm normality of data of mental health (garson ) . this test on the data confirmed normality (p = . ) and the absence of outliers. pearson's correlation test was then used to assess bivariate correlations between the variables. a multiple linear regression model was fitted to assess the influence of the changes in behaviors on mental health, with potential confounding variables adjusted for. before fitting the regression model, a sensitivity analysis was conducted to screen for relevant potential confounding variables in harmony with the procedure adopted elsewhere (rothman and greenland ; rezai et al. ) . in this analysis, univariate regression models were used to estimate crude coefficients (i.e. standardized and unstandardized coefficients and their % confidence intervals) indicating the influence of the covariates and changes in behaviors on mental health. covariates with p > . were removed and those with p ≤ . were kept for the second level of the sensitivity analysis. at this stage, only chronic disease status (cds) was removed. at the second level, multiple linear regression models were fitted to estimate coefficients (including their % confidence intervals) representing the influences of changes in behavior and each of the remaining covariates on mental health. any covariate that led to a % change (decrease or increase) in the coefficients of the behaviors from the first level was kept and incorporated into the final regression model (see table ) as a covariate. at this stage, age and income were removed. we achieved a survey completion rate of %, which means all participants (n = ) completed the survey. after applying the inclusion criteria, questionnaires were dropped. of the remaining questionnaires analyzed, % (n = ) were completed by residents of accra, % (n = ) by residents of kumasi; and % (n = ) by residents of tamale. as table indicates, about % (n = ) of participants were female and % (n = ) were male. about % of participants (n = ) had tertiary education, which means that most of the sample had a high education. the age of participants ranged between and years. table shows some dramatic changes in behaviors. that is, % of participants lost moderate physical activity time, with over similarly, more than % added at least h to their sedentary behavior time. about % (n = ) of participants were exercising during the lockdown, whereas there was no change in the frequency of smoking for % (n = ) of participants who were smokers. the frequency of alcohol intake increased for % (n = ) and did not change for % (n = ) of participants. the frequency of eating decreased for % (n = ) and increased for % (n = ) of participants. about % (n = ) of participants agreed they used substances to protect themselves against covid- and faced a higher risk of domestic violence. sexual activity decreased for % (n = ) and increased for % (n = ) of participants. appendix table shows a distribution of average mental health scores across categorical predictors. table shows some significant correlations at p < . and p < . . for example, mpatl and mental health are negatively correlated (r = − . ; p < . ; two-tailed). this result connotes that mental health decreases as moderate physical activity time lost increases. table shows regression coefficients resulting from this and other correlation coefficients in table . it can be seen that moderate pa time lost makes a significant influence on mental health (β = − . ; t = − . , p < . ), suggesting that mental health decreased with an increase in moderate pa time lost. sedentary behavior time added also made a negative influence on mental health (β = − . ; t = − . , p = . ). the influence of 'sf-unchanged' is about times lower compared with that of 'sf-non-smokers' (b = − . ; t = − . , p = . ), which indicates that the mental health of individuals who did not have a change in their smoking frequency was lower compared with non-smokers. the influence of 'ai-not applicable' on mental health is about times lower compared with that of 'ai-increased' (b = − . ; t = − . , p = . ), implying that individuals who did not drink alcohol at all reported lower mental health scores compared with those whose frequency of alcohol intake decreased. the influence of 'ai-unchanged' on mental health is about . times higher compared with that of 'ai-decreased' (b = . ; t = . , p = . ), indicating that individuals whose frequency of alcohol intake remained the same reported larger mental health scores compared with those who had a decrease in their frequency of alcohol intake. an increase in eating frequency (i.e. ef-increase) and a decrease in eating frequency (i.e. ef-decrease) were both associated with lower influences on mental health compared with 'ef-no change'. that is, compared with those whose eating frequency remained the same, individuals whose eating frequency increased or decreased reported lower mental health scores. those who used substances to protect themselves against covid- had better mental health compared with those who did not (b = . ; t = . , p < . ). finally, those with increased sexual activity (i.e. sa-increase) had better mental health compared with those whose sexual activity level did not change (β = . ; t = . , p = . ). the independence-of-errors and multicollinearity assumptions were met based on tolerance ≥ . (for each predictor) and durbin-watson = . (for the regression model) in table (garson ). a major change in behavior resulting from covid- -related social isolation is a reduction in physical activity and an increase in sedentary behavior time. ellingson et al. ( ) conducted in the us also backs our result with its evidence that a loss in moderate pa time and an increase in sedentariness is negatively associated with mental health in young adults. more so, several studies (walsh ; allen et al. ; shim et al. ; lund et al. ) reported a negative influence of reduced pa or increased sedentary behavior on mental health in the general population. unlike previous pieces of evidence however, our result is the first linked to social isolation driven by a pandemic. a noteworthy connotation of our result is that social distancing measures should be rolled out with pa promotion programs to encourage indoor pa during social isolation. it may thus be necessary for governments to intensify pa counseling via the media before and during a lockdown. as done in parts of the uk (mytton et al. ; anderson et al. ), gyms and parks should be considered essential service providers and allowed to operate during a lockdown. however, a strict observance of social distancing protocols at these pa centers is imperative. despite the strong force with which conspiracy theorists used the social media to promote smoking as a behavior that protects against covid- (li and siegrist ; anderson et al. ) , this study did not find any change in smoking among socially isolated participants. based on , we argue that this result may be due to the fact that over % of the sample were highly educated individuals who may not yield to unfounded claims. besides, smokers whose frequency of smoking did not change reported lower mental health scores than their colleagues who never smoked. this finding endorses previous studies that have found a negative relationship between smoking and mental health (lawrence et al. ; walsh ; allen et al. ; shim et al. ; lund et al. ) . coupled with other distressing conditions caused by social distancing during the spread of covid- , our result may be an indicator of an intensified consequence of smoking. in any case, campaigns discouraging smoking and related behaviors during a lockdown ought to be intensified. since the primary weapon for fighting many infectious diseases such as covid- is the individual's immunity, behaviors such as smoking that have the tendency of weakening or disabling the immune system (lawrence et al. ; lund et al. ) must be eschewed at the individual level. for this reason, there is no alternative to conscientizing smokers regarding the health risks of smoking, particularly for those socially isolated. a key change in behavior associated with covid- -related social isolation is a decrease and increase in the frequency of alcohol intake. interestingly, those who did not drink alcohol at all reported smaller mental health scores compared to those who maintained their frequency of alcohol intake. this outcome tends to support previous empirical studies (german and walzem ; kaplan et al. ; chiva-blanch and badimon ) confirming a positive table the association between mental health, changes in health behaviors, and covariates (n = ) b unstandardized coefficient, β standardized coefficient, ci confidence interval, s.e. standard error (of b), sbta sedentary behavior time added, mpatl moderate physical activity time lost, vpatl vigorous physical activity time lost, sf smoking frequency, ai alcohol intake, ef eating frequency, sa sexual activity, dvi domestic violence increase a dummy variable for smoking frequency with 'sf-non-smoker' as reference b dummy variable for alcohol intake with 'ai-decreased' as reference c dummy variable for eating frequency with 'ef-no change' as reference d dummy variable for sexual activity with 'sa-no change' as reference **p < . ; *p < . (kaplan et al. ; chiva-blanch and badimon ) have warned that excessive consumption of alcohol increases the risk of disease. this being so, an increase in the frequency of alcohol intake can cause a major public health concern, especially for those forced into social isolation owing to the spread of an infectious disease such as covid- . a change in the frequency of eating as a result of social isolation is a key finding of this study. while a fall in eating frequency may be due to poor access to supermarkets and supplies, an increase is possible for the working class or managerial elites with abundant food supplies. as social isolation during the lockdown compelled individuals to spend more time at home, an increase in the frequency of eating among those with enough savings is likely. this can be said of most of our participants who were highly educated and had a regular income. further to the above, an increase and decrease in the frequency of eating were associated with lower mental health scores, logically because an increase translated into abuse of food while a decrease resulted in malnutrition in the short-term. this thinking squares with studies (prentice ; fuhrman ) that have revealed that food can only confer its nutritional and health benefits when consumed in moderation. moreover, short-term side effects of over-and/or under-eating include mental health struggles that can compel individuals to poorly rate their mental health (prentice ; fuhrman ) . with these possibilities in view, programs for conscientizing residents facing a lockdown would have to be cognizant of potential changes in dietary behaviors. a segment of our sample used substances (e.g. garlic, ginger) to protect themselves against covid- during social isolation, which points to the likelihood that people were influenced by fake news regarding the protective properties of eating garlic, ginger, and other substances against covid- . more interestingly, those who used these substances reported higher mental health scores, an outcome that tends to add weight to claims that garlic, ginger, and similar substances have anti-inflammatory properties and therefore enhance the immune system and confer other health benefits (arreola et al. ; percival ) . we would want to reason that the foregoing result was possibly driven by participants' psychological reaction to using substances to protect themselves against covid- . that is, dependence on substances may have boosted the confidence of participants in their health and consequently made them to overrate their mental health. whether substance use was well-fated or a guise, it is understandable that people are likely to use unprescribed substances during the lockdown to protect themselves against covid- . regardless of its impact on mental health in this study, substance use could mar individual and public health, thereby causing disabilities that may cost governments a fortune to rehabilitate. over the years, empirical research has produced mixed findings regarding the influence of sex on mental health (bennett ; galinsky and waite ) , but researchers, from a psychology perspective, have reasoned based on different scenarios that mental health could improve with sexual activity (ganong and larson ) . congruent with this stance is our result indicating an increase in mental health in those whose sexual activity increased. a common explanation to a positive influence of sexual activity on mental health is that sexual intercourse and romance increase individuals' happiness and satisfaction with life if they satisfy the individuals emotional needs (bennett ; galinsky and waite ) . we opine based on this argument that sexual activity would make a positive short-term influence on mental health during covid- -related social isolation. we would want to premise this stance around the idea that sexual activity in the early days of the lockdown may have provided total emotional satisfaction possibly because most participants, who make up an elite working class, did not have enough time for sex before the lockdown. as such, the participants had unsatisfied sexual needs before they went into social isolation. psychologists explain that an increase in sexual activity to meet one's unsatisfied sexual needs always produces mental health benefits (galinsky and waite ) . drawing on the foregoing assertion, we admit that changes in behaviors and their influences on mental health may differ in the long run when people may successfully adapt to the lockdown or use up economic resources saved. moreover, the dynamics may differ from what was explained based on the disengagement theory and fbm in the shortterm, leading to a more or less compelling changes in behaviors. we, therefore, concede that focusing on short-term changes in this study is a major shortcoming that future researchers should address. this said, further studies may adopt randomized longitudinal designs to assess the impact of time on the changes considered in this study as well as their effects on mental health. we are also worried that our sample was not powered and may, as a result, not be representative of the general population. while we believe findings of this study may apply to some settings owing to the normal distribution of our data (garson ; yap and sim ) , it is important for future studies to use representative samples to enhance the generalizability of our results. the replication of this study in new contexts may suffice in situations where the use of a powered or representative sample is not possible. some segments of the population (e.g. older people) who did not use the internet were not included in the sample. with english serving as the sole medium of questionnaire administration, residents with poor english skills may have been underrepresented. despite these limitations, this study is novel for being the first to assess changes in behaviors that may result from self-isolation during the spread of an epidemic. it does not only provide a foundation for future research but also offers insights into what stakeholders could do to ensure that behavior changes do not compound public health issues accompanied by the spread of an epidemic or a related extreme event. at least, this study makes us to contemplate the need for covid- social distancing measures to be rolled out alongside public education programs for discouraging unhealthy changes in behaviors. the study confirms short-term changes in behaviors attributable to covid- -related social isolation, with key examples being a reduction in individuals' physical activity time and an increase in sedentary behavior time. sexual activity and eating frequency have changed in the short-term owing to covid- -related social isolation. an increase in sedentary behavior time has made the most compelling negative influence on mental health, which suggests that the biggest decline in mental health in our sample was due to increased sedentariness. the only change in behavior that has a positive influence on mental health is substance use. for the most part, changes in behaviors in the short-term attributable to covid- social isolation were associated with lower mental health scores. these changes in behavior are, therefore, potential public health risks that may compound over time. see table . social determinants of mental health how will country-based mitigation measures influence the course of the covid- epidemic? the lancet covid- and the consequences of isolating the elderly. the lancet public health immunomodulation and anti-inflammatory effects of garlic compounds a review of web based interventions focusing on alcohol use adolescent mental health and risky sexual behaviour the psychological impact of quarantine and how to reduce it: rapid review of the evidence. the lancet opinion wuhan coronavirus ( -ncov): the need to maintain regular physical activity while taking precautions benefits and risks of 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on environmental and socio-economic systems: what makes the difference? social media and online survey: tools for knowledge management in health research green space and physical activity: an observational study using health survey for england data aged garlic extract modifies human immunity overeating: the health risks investigation of three clusters of covid- in singapore: implications for surveillance and response measures. the lancet guide to the design and application of online questionnaire surveys the association between prevalent neck pain and health-related quality of life: a cross-sectional analysis philadelphia: lippincott-raven the social determinants of mental health the psychological impact of covid- on the mental health in the general population the social determinants of mental health: an overview and call to action covid- pandemic and mental health consequences: systematic review of the current evidence lifestyle and mental health comparisons of various types of normality tests acknowledgements we thank members of the 'share research-ace' whatsapp team including dr samuel awuni azinga and mr wisdom mensah avor for their technical advice and guidance. we acknowledge hon. kojo yankah for proofreading this manuscript. author contributions na conceived the research project and wrote the manuscript. ffo coordinated data collection and survey administration. em analysed the data. swm contributed to survey design, validation, and data collection. hkm and fq contributed to the design of the survey and formatted the manuscript. all authors read and approved the draft manuscript.funding the researchers did not receive funding for this study. conflict of interest the authors declare that they have no conflict of interest.ethical approval this study was approved by the institutional ethics review board (with code # -ace). the board ensured that participation in the study was voluntary and the study was not harmful to participants.informed consent every participant provided informed consent before completing the survey. see table . key: cord- - p xten authors: norr, aaron m.; katz, andrea c.; nguyen, janelle l.; lehavot, keren; schmidt, norman b.; reger, greg m. title: pilot trial of a transdiagnostic computerized anxiety sensitivity intervention among va primary care patients date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: p xten people in need of mental health treatment do not access care at high rates or in a timely manner, inclusive of veterans at department of veteran's affairs (va) medical centers. barriers to care have been identified, and one potential solution is the use of technology-based interventions within primary care. this study evaluated the cognitive anxiety sensitivity treatment (cast), a previously developed computerized treatment that has shown efficacy in community samples for mental health symptoms including: anxiety, depression, post-traumatic stress, and suicidal ideation. va primary care patients with elevated anxiety sensitivity (n = ) were recruited to participate in a mixed-method open pilot to examine acceptability, usability, and preliminary effectiveness in a va primary care setting. participants completed an initial visit, that included the intervention, and a one-month follow-up. veterans found cast to be generally acceptable, with strong usability ratings. qualitative analyses identified areas of strength and areas for improvement for use with va primary care veterans. repeated measures ancovas revealed significant effects for symptoms of anxiety, depression, traumatic-stress, and suicidal ideation. cast could potentially have a large public health impact if deployed across va medical centers as a first-step intervention for a range of mental health presenting concerns. people in need of mental health treatment typically do not access care at high rates or in a timely manner. nationally representative, population-based research suggests that only % of those with mental health disorders access treatment the year prior and only % receive minimally adequate treatment, if any treatment at all (wang et al., ) . delays from mental health disorder onset to treatment initiation can span years, with the average delay reaching a decade in the u.s. (wang et al., ) . problems accessing mental health care persist for some in the department of veterans affairs (va; keller & tuerk, ; maguen et al., ) . for example, thirty-five percent of operation enduring freedom/operation iraqi freedom (oef/oif) veterans at the va meet criteria for at least one mental health diagnosis. even with improvements in access to treatments for some mental health disorders (karlin & cross, ; goldberg et al., ) many veterans never access mental health care, or do not received adequate doses of mental health care, despite the presence of impairing mental health symptoms (brown & jones, ; seal et al., ; teich et al., ) . veteran barriers to care have been specified (e.g., bovin et al., ; possemato et al., ; tanielian & jaycox, ) , including concerns about stigma, medication side effects, confidentiality, and logistical barriers such as veteran schedule and access. to address these issues, and consistent with national healthcare priorities (institute of medicine, ), va has aggressively pursued the embedding of mental health specialists in primary care (department of pilot trial of cast among veterans veterans affairs, ) . integrated mental health allows for the treatment of mild to moderate psychiatric disorders and behavioral health problems in primary care, with on-going symptom assessment and a stepped-care approach to referrals to additional mental health interventions. in stepped-care approaches, patients are started with the least intensive treatment and are offered more intensive treatments as needed (bower & gilbody, ) . this approach is thought to have the potential to increase both treatment engagement and efficiency in proving mental health care. indeed, embedding mental health specialists in primary care and employing a stepped-care approach has been shown to improve access to mental health services (leung et al., ; leung et al., ) . technology-based interventions can play an important role in integrated mental health stepped-care approaches to treatment (e.g., espie, ; green & iverson, ), as they address some barriers to care by drawing on convenience, the ability to reach individuals in remote locations and on the patient's schedule, and the elimination of face-to-face meetings with clinicians, thereby reducing stigma associated with seeing a mental health professional. one highly promising technology-based intervention for mental health symptoms is the cognitive anxiety sensitivity treatment (cast; schmidt et al., ) . cast specifically targets anxiety sensitivity, or a fear of anxiety and related sensations, which has been shown to be a transdiagnostic risk factor that contributes to the development and maintenance of a variety of mental health symptoms, including anxiety, depression, post-traumatic stress, and suicidal ideation (capron et al., ; marshall et al., ; naragon-gainey, ) . cast is a fully computerized, -minute intervention that comprises education about the nature of anxiety symptoms and a guided interoceptive exposure exercise (i.e., voluntary hyperventilation), which pilot trial of cast among veterans is a well-established, highly effective intervention for reducing fearful responding to anxiety sensations (schmidt & trakowski, ) . cast has demonstrated efficacy in reducing symptoms of ptsd, anxiety, depression, and suicidal ideation in multiple randomized controlled trials (schmidt et al., (schmidt et al., , short et al., a) , but limited research exists among veterans. a secondary analysis (short et al., b) of cast users from a previous randomized clinical trial (schmidt et al., ) found that the sub-set community-dwelling veterans in the sample reported moderate or higher usability and applicability, and veterans' acceptability ratings were modestly higher than non-veteran participants. another study evaluated cast among veterans engaged in a va intensive outpatient treatment for opioid use disorder. this study reported adequate acceptability/usability and a medium effect size for reductions in anxiety sensitivity. small-to-medium effect size reductions were found for depression, anxiety, and stress. notably, neither of these prior studies examined acceptability of cast among veterans engaged with primary care at va, and neither included qualitative methods to determine areas for improvement for use with veterans. veterans in primary care present with a broad range of needs, broad range of symptoms (seal et al., ) , and are arguably an ideal population and setting to deploy a first-step intervention, a single-session, transdiagnostic intervention (bower & gilbody, ) such as cast due to the potential of eliminating the potential barriers associated with referral to specially mental health. examining acceptability, usability, and preliminary efficacy of cast, and gathering critical qualitative feedback to determine potential areas for improvement is an essential next step towards successfully deploying this intervention, and other similar interventions, within a large healthcare system like va. this study evaluated the use of the cast program in va primary care patients through an open, pilot trial. the primary outcomes were traumatic stress, anxiety, and depressive symptoms. qualitative feedback was collected to assess acceptability and usability of the intervention as well as to determine potential areas of improvement for using cast with veterans within a primary care setting. study aims were to: ( ) collect user feedback from veterans regarding the acceptability/usability of cast and potential areas of improvement for use with veterans, and; ( ) investigate the preliminary efficacy of cast in reducing mental health symptoms (anxiety, depression, and ptsd) among veterans enrolled in va primary care. us military veterans (n = ) were recruited from a large va medical center via referrals from healthcare providers, flyers/brochures, and staffed waiting area tables in the primary care clinic and outpatient mental health clinic. veterans were invited to participate in a study examining a "computerized treatment for stress and anxiety." veterans were eligible if they were ( ) enrolled in primary care at the va facility and ( ) scored at least sd above the community mean on the anxiety sensitivity index- (asi- ) cognitive subscale (score of > ; taylor et al., ) . exclusionary criteria included: ( ) age greater than , ( ) women who are pregnant, ( ) history of stroke, seizure, irregular heartbeat, or heart failure, ( ) uncontrolled chronic obstructive pulmonary disease (copd), emphysema, or asthma. given the study team's inability to provide medical clearance for participation, exclusionary criteria were selected in consultation with a physician to ensure no negative side effects of the interoceptive exposure exercise (voluntary hyperventilation) among individuals with these characteristics. participants were on average . years old (sd = . ) and the majority identified as male ( %) and caucasian ( %). full sample demographics can be found in table . - (asi- ) . the asi- is an -item questionnaire used to assess fear of anxiety-related sensations and has been validated in community and clinical samples (taylor et al., ) . participants rate the degree to which they agree with each item on a -point scale ranging from "very little" to "very much". higher scores indicate a greater fear of anxiety-related sensations. the asi- was administered at baseline, post-intervention, and at -month follow-up. in the current sample the asi- demonstrated excellent internal consistency at baseline (α = . ). the gad- (spitzer et al., ) is a item questionnaire designed to assess anxiety symptoms. the gad- has been widely validated and is commonly used clinically in the va to assess for symptoms of anxiety. participants rate how often they have been bothered by specific symptoms on a -point scale ranging from "not at all" to "nearly every day". the gad- was administered at baseline and at the -month followup. in the current sample the gad- demonstrated good internal consistency at baseline (α = . ). the phq- (spitzer et al., ) is a item questionnaire designed to assess symptoms of depression. the phq- has been widely validated and is used in routine practice in the va to assess for symptoms of depression. participants rate how often they have been bothered by specific symptoms on a -point scale ranging from "not at all" to "nearly every day". the phq- was administered at baseline and at the -month follow-up. consistent with many previous studies (e.g., louzon et al., ; pilot trial of cast among veterans al., ), item ("thoughts that you would be better off dead, or of hurting yourself") was used as an efficient means to examine suicidal ideation. in the current sample the phq- demonstrated excellent internal consistency at baseline (α = . ). the pcl- (weathers et al., ) is a item questionnaire designed to assess the symptoms of ptsd. the pcl- has been widely validated and is commonly used clinically in the va to assess for symptoms of ptsd. participants rate how much they have been bothered by specific symptoms on a -point scale ranging from "not at all" to "extremely". the pcl- was administered at baseline and at the month follow-up. in the current sample the pcl- demonstrated excellent internal consistency at baseline (α = . ). the sus is a widely used, -item self-report questionnaire that assesses the usability of technology systems (brooke, ) . participants rate their experience with the usability of the computer program on a -point scale ranging from "strongly disagree" to "strongly agree". the sus was administered post-intervention and demonstrated good internal consistency (α = . ). the aq is an -item questionnaire designed to assesses the subjects' perceived acceptability of, and engagement with, the cast program across various domains and the items have been used in previous studies examining the cast program (norr et al., a; raines et al., ; short et al., b) . the aq was administered post-intervention. two qualitative interviews were conducted (at post-intervention and -month follow-up) to assess participants' user experiences with the cast program. the questions were designed by study investigators to identify areas for improvement in future iterations of the program. responses were summarized, transcribing word for word when possible, by a study research coordinator during the interview. for this analysis, only data from the interview administered post-intervention was included. the specific questions were: "what did you like about the program?", "what did you not like about the program?", and "what are three ways this program can be improved for use specifically with veterans?". a pre-enrollment study screen to determine eligibility was conducted in person or over the phone by a study research coordinator and lasted approximately - minutes including completion (written or verbal) of the asi- cognitive subscale. volunteers deemed initially eligible were then scheduled for the first study visit. at the initial study visit, participants were provided with an overview of the study and completed written informed consent. after informed consent, participants completed baseline self-report measures that assessed demographics, current and past mental health treatment, as well as symptoms of anxiety, depression, and ptsd. once baseline measures were completed, participants were instructed on how to navigate the cast program on a laptop computer. after completing cast ( minutes), participants completed post-treatment questionnaires to assess changes in anxiety sensitivity levels from baseline, along with rating the acceptability/usability of the cast program in a va setting. following all questionnaires, participants completed a qualitative interview with a study pilot trial of cast among veterans coordinator trained in rapid qualitative inquiry (e.g., reger et al., ) by an experienced doctoral-level qualitative researcher. the entire in-person visit lasted approximately hours. at the one-month follow-up visit, participants completed a questionnaire packet to measure symptom change and another qualitative interview to give participants the opportunity to provide additional feedback about the cast intervention. this entire in-person visit lasted approximately - minutes. program consists of slides that contain video animation and audio narration throughout, as well as interactive features, such as brief-intermittent quizzes to promote comprehension. participants start with psychoeducation on anxiety-related sensations (e.g., elevated heart rate, difficulty concentrating) and are provided corrective information aimed at dispelling myths commonly held by individuals with high anxiety sensitivity. participants are then shown how to complete interoceptive exposures through a guided video and are told that these exposures can help correct their conditioned fear to anxiety-related sensations. participants then complete ten, -second guided hyperventilation trials and are asked to rate after each trial the intensity of the sensations experienced and their subjective distress. after completing the hyperventilation trials, the participant's responses are graphed by the program to demonstrate any changes over the course of the trials. pilot trial of cast among veterans to examine changes in as from baseline to post (n = ) paired samples t-tests were utilized. changes in as and symptoms over the period from baseline to follow-up (n = ), were examined with repeated measures ancovas (baseline and -month follow-up time points). the number of individual and group mental health appointments (assessed via medical record review) during the study period (baseline to -month follow-up) were included as covariates to control for the effect of mental health appointment attendance over the course of the study. only participants who completed both measurement points for the test of interest were included. matrix analysis was used to evaluate the qualitative interview data, which provides a visual template of the systematic coding and categorization process of the pattern of responses collected from participants (averill, ) . first, two subject matter experts (amn and gmr) reviewed all interview responses and independently created proposed categories for the matrix. these proposed categories were then reconciled with one another, and the final coding categories were placed along the top of the matrix. next, two research team members (ack & jln) independently coded responses vertically under the corresponding category to display trends and frequency of the responses per category splitting by strengths and weaknesses. all disagreements were reconciled through discussion between the coders. item-level results from the aq can be seen in table . the majority of participants rated cast as at least "moderately easy" to understand ( %), "moderately easy" or "easy" to follow ( %), at least "moderately helpful" ( %), at least "somewhat engaging" ( %), "somewhat interesting" or "very interesting" ( %), and at least "somewhat applicable" to daily life ( %). the majority of participants also found cast to be "somewhat applicable" or "very applicable" to stressors during military service ( %). eighty-eight percent of participants reported that they were "somewhat likely" or "very likely" to use the information and techniques learned. sus scores (m = . , sd = . ) demonstrated good-to-excellent usability and were higher than average sus scores found through meta-analytic work (m = ; bangor et al., ) . qualitative data indicated that user reactions to the cast intervention largely fell into four domains: usability of the program, quality of content presented, impact of the intervention on the participant, and its applicability to military and veteran populations. participants generally highlighted both strengths and weaknesses within each of these domains (see table ). when discussing the program's usability and design, participants appreciated that the cast program was straightforward, easy to use, and easy to understand. others appreciated the auditory component of the program, commenting on the narrator's voice, tone, and pace while delivering the information. veterans also noted cast's overall structure helped with usabilitythat the layout, order, visual aids, and quizzes solidified their learning. veterans highlighted three areas of weakness in cast's usability. first, they suggested that breaks be built into the intervention so that information is easier to absorb. second, others took issue with the computer-only format and voiced a desire to discuss the ideas presented in a larger group setting. finally, veterans noted some technical difficulties that interfered with the program, such as long buffering time slowing the intervention down, distracting flashing between slides, and difficulty viewing the information against a dark background. when commenting about the content of cast, many study participants appreciated the education on myths and facts about stress and anxiety and the physiological components of stress, noting they learned something new. when considering the weaknesses of the content, several veterans highlighted their desire for more information, such as about how stress manifests in different psychiatric diagnoses, specific information about post-traumatic stress disorder, and how to apply these skills to stress in the moment. in addition, some veterans objected to the myths and facts element of the education, as the "facts" presented did not fit their worldviews. participants had mixed views on the breathing exercises. though many highlighted the practical exercises as strengths of the intervention which allowed them to solidify their learning and practice a useful skill, others had difficulty with them and found them distressing. the fewest responses fell into the impact and outcome domain. regarding strengths within this domain, several participants were pleased with the observed improvements in their stress levels after completing cast, and others commented on the lasting knowledge they gained through participation. one veteran voiced disappointment that their stress symptoms did not improve during the intervention. finally, when considering cast's relevance to military and veteran populations, many participants found the program quite relatable to veterans' issues. however, others thought that the inclusion of more combat-and military-specific examples, more visuals of women veterans (including the option for a female narrator), and information about ptsd specifically would help the program be more relevant. veterans also noted how useful this program might be among veterans, as many comments included a call for additional outreach to make it more widely available, including delivery in a remote format that would not require presenting to the medical center. paired samples t-test revealed medium effects for baseline to post cast change in asi- total (Δm = . , Δsd = . ; t ( ) = . . p = . ; d = . ), asi- physical (Δm = . , Δsd repeated measures ancovas, controlling for mental health appointment attendance between study visits, revealed medium-to-large effects on asi- , gad- , phq- , pcl- and suicidal ideation (phq- item ) from baseline to -month follow-up (see table for full results). the purpose of the current study was to examine the acceptability, usability, and preliminary effectiveness of a transdiagnostic computerized intervention for anxiety sensitivity focused on va primary care patients. results from the acceptability questionnaire revealed the majority of participants found the intervention acceptable across eight different domains, and usability scores (sus) were higher than meta-analytic averages (bangor et al., ) . these results are consistent with prior work examining acceptability of cast among veterans in an academic setting (short et al., b) and among veterans in a va opioid use disorder intensive outpatient program (raines et al., ) . results from the qualitative analysis fleshed out these results and provided rich data on several areas of strength as well as areas for potential improvement. veterans appreciated the pilot trial of cast among veterans information being presented both visually and auditorily, citing this bimodal presentation as helpful for engagement and for understanding the content. further, they appreciated that the information was presented in a straightforward manner while focusing on specific knowledge they can carry forward with them to better understand their experience of anxiety and stress symptoms. some veterans even requested more information on anxiety and stress symptoms, highlighting the importance of the educational component. as psychoeducation has been shown to be effective across many different treatment settings and outcomes (e.g., norr et al, b; perry et al., ; powell et al., ) , finding ways to increase accessibility to psychoeducational content could be one method to further engage veterans in primary care in mental health treatment. veterans expressed interest in having more cast content examples that are specific to veterans/military service and requested opportunities to discuss the content with other veterans. these responses highlight the importance of military culture and of peers in providing competent care to veterans and service members (meyer & wynn, ) . veterans also expressed optimism with employing an outreach program to get this intervention into the hands of veterans who may be more apprehensive about engaging with traditional mental health services. this feedback encourages continued efforts by the va and the department of defense to create and disseminate non-traditional treatment options including internet-based and mobile health applications (gould et al., ) . while the current study examined completion of cast at an in-person, research appointment at a va medical center, prior work has suggested effectiveness of cast when delivered remotely via the internet (norr et al., a) . such an approach could be a useful way to engage veterans who are not willing to attend in-person appointments, and pilot trial of cast among veterans could be particularly advantageous when in-person care is not possible, for example during a pandemic as seen with covid- . regarding the intervention's efficacy, the current study saw significant, medium-sized decreases in as between baseline and posttest (d = . ) and baseline to -month follow-up (d = . ). these effect sizes are commensurate with studies examining cast among undergraduate rct; d = . ) and community participants (schmidt et al., ; rct; d = . ) in an academic setting as well as among veterans in a va opioid use disorder intensive outpatient program (raines et al., ; open pilot; glass's Δpre of . ). results also revealed significant reductions, with large effects, for anxiety symptoms, depressive symptoms, ptsd symptoms, and suicidal ideation. the demonstrated reductions across a range of psychological symptoms is consistent with prior randomized controlled trials of cast among community participants (schmidt et al., ; schmidt et al., ) . these results suggest cast program could be efficacious among va primary care patients, and therefore has the potential to be a highly efficient and scalable treatment in a va primary care setting with regard to both time investment from patients and resource investment from the va system. as a healthcare system, the va faces unique challenges associated with enacting mental healthcare among a population that can be challenging to engage (seal et al., ) . results from the current study suggest that the single-session cast program could be an acceptable, effective, and efficient way to provide evidence-based mental health care to va primary care patients. the results from the current study are promising given many veterans express negative beliefs about mental health treatment generally (fox et al., ) and identify barriers to receiving mental healthcare within a va setting (cheney et al., ) , demonstrating the need for novel treatment delivery methods. thus, cast would help address these national priorities pilot trial of cast among veterans to integrate mental health care into medical settings (institute of medicine, ) to overcome some of these barriers to care as it can be deployed without trained mental health providers. similarly, cast could be offered as a first step within a stepped-care model (bower & gilbody, ) with veterans graduated to higher levels of care as indicated. indeed some veterans in the current study commented they wanted follow-up in a group or individual setting, while others did not. thus, having a non-traditional treatment option, such as cast, be offered in a primary care setting could help engage veterans who would otherwise not engage in mental health care, or who might further delay accessing care due to stigma about mental health treatment. the current study is not without limitations. first, all veterans who participated in the current study were either currently ( %) or previously engaged in psychotherapy ( %). thus, though all participants were va primary care patients, it is possible that the results would be different for a sample of va primary care patients who were naïve to mental health treatment. however, these patients likely offer an important perspective as they are aware of other mental health treatment experiences. similarly, the results of the current study suggest that the cast intervention can confer benefit even for those who have already received more traditional mental health care. second, the single group design of the current study limits the ability to draw conclusions about the causal nature of the observed reductions in symptoms. importantly, we controlled for the number of mental health (individual and group) appointments attended over the course of the study to ensure results were not simple associated with mental health appointment attendance. third, the current study utilized a single item measure of suicidal ideation. though a more comprehensive measure of suicide risk may provide a more nuanced perspective, research in a large sample (louzon et al., ; n= , ) of veterans found that a single item measure of si significantly predicted suicide mortality (hr = . ), supporting the pilot trial of cast among veterans utility of measuring si in this fashion. forth, for the qualitative portion of the study we relied on interviewer notes to capture response themes. it is possible this method could have resulted in missing information that would have been captured with audio recorded transcripts. finally, though cast was completed on the computer, all sessions were completed at the va facility in the presence of a research coordinator. it is possible that completing this intervention remotely would yield a different treatment experience and results. prior work suggests that completing cast remotely confers benefit (norr et al., a) , however, future research should investigate this among a va population. important areas of future research include examining the efficacy of cast for mental health treatment naïve veterans, utility of employing cast within a stepped care model embedded in primary care, and efficacy of cast when delivered remotely to va primary care patients to determine whether an in-office visit is needed. despite these limitations, the strong evidence of efficacy among community participants from prior randomized controlled trials coupled with the results from the current study further promote potential of cast, and similar treatments, to reach veterans who otherwise would not receive care. veterans found this treatment experience to be highly acceptable and reported benefit with regard to symptoms of anxiety, depression, ptsd, and suicidal ideation. involving veterans in the collaborative development of these types of interventions is consistent with best practices in human centered design and is critical to achieving products veterans find to be culturally competent. the results for the current study point to potential areas of improvement for cast such as including more military relevant example and having the option for further engagement with this material via a group setting following the completion of cast. additional research is needed to explore feedback from mental health treatment naïve veterans to examine the effects of cast on future engagement in mental health care, and to evaluate the program pilot trial of cast among veterans delivered via a remote format. however, given the low cost of scaling and disseminating cast (norr et al., a) , the results of the current study suggest the possibility of cast having a large public health impact across va medical centers nationwide as a first-step intervention for a range of mental health presenting concerns. weakness "break up the information, not all in one session. allow for discussion with others, put it into a group session." "dark theme should change to a lighter theme" "recognizing the stress is one thing, education about how to handle the stress would be helpful." "too absolute in the 'facts' presented in the programdoesn't apply to all people." "ten times for breathing exercises was stressful" "did not improve stress symptoms" "more examples that relate to veterans specifically rather than civilians (different types of stress)." "adding more material related to combat, questions and examples. . . more female veterans. female specific program would be helpful." pilot trial of cast among veterans table . changes in clinical variables from baseline to -month follow-up note. asi- = anxiety sensitivity index - ; gad- = generalized anxiety disorder - ; phq- = patient health questionnaire - ; pcl- = ptsd checklist for dsm- . matrix analysis as a complementary analytic strategy in qualitative inquiry an empirical evaluation of the system usability scale veterans' experiences initiating va-based mental health care stepped care in psychological therapies: access, effectiveness and efficiency: narrative literature review sus-a quick and dirty usability scale. usability evaluation in industry mental health and medical health disparities in transgender veterans receiving healthcare in the veterans health administration: a casecontrol study veteran-centered barriers to va mental healthcare services use vha handbook . : uniform mental health services in va medical centers and clinics stepped care": a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment attitudes about the va health care setting, mental illness, and mental health treatment and their relationship with va mental health service use among female and male oef/oif veterans mental health treatment delay: a comparison among civilians and veterans of different service eras veterans affairs and the department of defense mental health apps: a systematic literature review computerized cognitive-behavioral therapy in a stepped care model of treatment mental disorders and mental health treatment among us department of veterans affairs outpatients: the veterans health study board on the health of select populations, & committee on the assessment of ongoing efforts in the treatment of posttraumatic stress disorder from the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the u.s. department of veterans affairs health care system evidence-based psychotherapy (ebp) non-initiation among veterans offered an ebp for posttraumatic stress disorder changing patterns of mental health care use: the role of integrated mental health services in veterans affairs primary care veterans health administration investments in primary care and mental health integration improved care access does suicidal ideation as measured by the phq- predict suicide among va patients? time to treatment among veterans of conflicts in iraq and afghanistan with psychiatric diagnoses anxiety sensitivity and ptsd symptom severity are reciprocally related: evidence from a longitudinal study of physical trauma survivors the importance of us military cultural competence meta-analysis of the relations of anxiety sensitivity to the depressive and anxiety disorders evaluating the unique contribution of intolerance of uncertainty relative to other cognitive vulnerability factors in anxiety psychopathology online dissemination of the cognitive anxiety sensitivity treatment (cast) using craigslist: a pilot study is computerized psychoeducation sufficient to reduce anxiety sensitivity in an at-risk sample?: a randomized trial effects of prolonged exposure and virtual reality exposure on suicidal ideation in active duty soldiers: an examination of potential mechanisms development of a guided internet-based psycho-education intervention using cognitive behavioral therapy and selfmanagement for individuals with chronic pain facilitators and barriers to seeking mental health care among primary care veterans with posttraumatic stress disorder stress and coping in social service providers after superstorm sandy: an examination of a postdisaster psychoeducational intervention a computerized anxiety sensitivity intervention for opioid use disorders: a pilot investigation among veterans barriers and facilitators to mobile application use during ptsd treatment: clinician adoption of pe coach interoceptive assessment and exposure in panic disorder: a descriptive study randomized clinical trial evaluating the efficacy of a brief intervention targeting anxiety sensitivity cognitive concerns a randomized clinical trial targeting anxiety sensitivity for patients with suicidal ideation bringing the war back home: mental health disorders among us veterans returning from iraq and afghanistan seen at department of veterans affairs facilities va mental health services utilization in iraq and afghanistan veterans in the first year of receiving new mental health diagnoses a randomized clinical trial examining the effects of an anxiety sensitivity intervention on insomnia symptoms: replication and extension acceptability of a brief computerized intervention targeting anxiety sensitivity validation and utility of a self-report version of prime-md: the phq primary care study a brief measure for assessing generalized anxiety disorder: the gad- invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery robust dimensions of anxiety sensitivity: development and initial validation of the anxiety sensitivity index- utilization of mental health service by veterans living in rural areas delays in initial treatment contact after first onset of a mental disorder twelvemonth use of mental health services in the united states the ptsd checklist for dsm- (pcl- ) contributions: aaron norr designed the study/analyses and contributed to writing all parts of the, methods, results, and discussion sections. andrea katz contributed to the qualitative analyses and contributed to writing the results section. janelle nguyen collected data, contributed to the qualitative analyses, and contributed to the writing of the methods section. keren lehavot contributed to the design of the study and provided feedback and edits to the manuscript. norman schmidt created the cast intervention and provided feedback and edits to the manuscript. greg reger provided crucial feedback and edits throughout study design, analysis, and writing of the manuscript. all of the authors have agreed to the author order and to submission of the manuscript in this form. key: cord- -mwitcseq authors: bu, f.; steptoe, a.; mak, h. w.; fancourt, d. title: time-use and mental health during the covid- pandemic: a panel analysis of , adults followed across weeks of lockdown in the uk date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: mwitcseq there is currently major concern about the impact of the global covid outbreak on mental health. but it remains unclear how individual behaviors could exacerbate or protect against adverse changes in mental health. this study aimed to examine the associations between specific activities (or time use) and mental health and wellbeing amongst people during the covid pandemic. data were from the ucl covid social study; a panel study collecting data weekly during the covid pandemic. the analytical sample consisted of , adults living in the uk who were followed up for the strict week lockdown period from st march to st may . data were analyzed using fixed effects and arellano bond models. we found that changes in time spent on a range of activities were associated with changes in mental health and wellbeing. after controlling for bidirectionality, behaviors involving outdoor activities including gardening and exercising predicted subsequent improvements in mental health and wellbeing, while increased time spent on following news about covid predicted declines in mental health and wellbeing. these results are relevant to the formulation of guidance for people obliged to spend extended periods in isolation during health emergencies, and may help the public to maintain wellbeing during future pandemics. a number of studies have demonstrated the negative psychological effects of quarantine, lockdowns and stay-at-home orders during epidemics including sars, h n influenza, ebola, and covid- - . these effects include increases in stress, anxiety, insomnia, irritability, confusion, fear and guilty [ ] [ ] [ ] . to date, much of the research on the mental health impact of enforced isolation during the pandemic has focused on the mass behavior of "staying at home" as the catalyst for these negative psychological effects. but there has been little exploration into how specific behaviors within the home might have differentially affected mental health, either exacerbating or protecting against adverse psychological experiences. re-allocation of time use has been shown from other social shocks where people suddenly are forced to spend a significant amount of time at home, with individuals quickly having to adapt behaviorally to new circumstances and develop new routines. for example, during the - recession, adults in the us who lost their jobs reallocated % of their usual working time to "non-market work", such as home production activities (e.g. cleaning, washing), childcare, diy, shopping, and care of others, and spent % of the time on leisure activities, including socializing, watching television, reading, sleeping, and going out . similarly, during the covid- pandemic, research suggests that while many individuals were able to continue working from home, others experienced furloughs or loss of employment, and many had to take on increased childcare responsibilities . further, individuals globally experienced a sharp curtailing of leisure activities, with shopping, day trips, going to entertainment venues, face-to-face social interactions, and most activities in public spaces prohibited. analyses of google trends have suggested negative effects of these limitations on behaviors, showing a rise in search intensity for boredom and loneliness alongside searches for worry and sadness during the early weeks of lockdown in europe and the us . but it's not yet clear what effect these changes in behaviors had on mental health. there is a substantial literature on the relationship between the ways people spend their time and mental health. certain behaviors have been proposed to exert protective effects on mental health. for instance, studies on leisure-time use show that taking up a hobby can have beneficial effects on alleviating depressive symptoms , engaging in physical activity can reduce levels of depression and anxiety and enhance quality of life [ ] [ ] [ ] [ ] , and broader leisure activities such as reading, listening to music, and volunteering can reduce depression and anxiety, increase personal empowerment and optimism, foster social connectedness, and improve life satisfaction [ ] [ ] [ ] [ ] [ ] . however, other behaviors may have a negative influence on mental health. engaging in productive activities (e.g. work, housework, caregiving) has been found in certain circumstances to be associated with higher levels of depression , and sedentary screen time can increase the risk of depression , especially when watching news or browsing internet relating to stressful events. this relationship between time use and mental health is bidirectional, as mental ill health has been shown to predict lower physical activity , lower motivation to engage in leisure activities and increased engagement in screen time . however, there have been little data on the association between daily activities and mental health amongst people staying at home during the covid- pandemic. further, it is unclear if activities that are usually beneficial for mental health had similar psychological benefits during the pandemic. this topic is pivotal as understanding time use will help in formulating healthcare guidelines for individuals continuing to stay at home due to quarantine, shielding, or virus resurgences during the current global crisis and in potential future pandemics. therefore, this study involved analyses of longitudinal data from over , adults captured during the first two months of 'lockdown' due to the covid- pandemic in the uk. it explored the time-varying relationship between a wide range of activities and mental health, including productive activities, exercising, gardening, reading for pleasure, hobby, communicating with others, following news on covid- and sedentary screen time. specifically, given research showing the inter-relationship yet conceptual distinction between different aspects of mental health, we focused on three different outcomes. anxiety combines negative mood states with physiological hyperarousal, while depression also combines negative mood states with anhedonia (loss of pleasure), and life satisfaction is an assessment of how favorable one feels towards one's attitude to life , . crucially, symptoms of anxiety and depression can coexist with positive feelings of subjective wellbeing such as life satisfaction, and even in the absence of any specific symptoms of mental illness, individuals can experience low levels of wellbeing . so this study sought to disentangle differential associations between time use and multiple aspects of mental health. as these relationships can be complex and are likely bidirectional, this study explored (a) concurrent changes in behaviors and mental health to identify associations over time, and (b) whether changes in behaviors temporally predicted changes in mental health, accounting for the possibility of reverse causality by using dynamic panel methods. participants data were drawn from the ucl covid- social study; a large panel study of the psychological and social experiences of over , adults (aged +) in the uk during the covid- pandemic. the study commenced on st march involving online weekly data collection from participants for the duration of the covid- pandemic in the uk. whilst not random, the study has a well-stratified sample that was recruited using three primary approaches. first, snowballing was used, including promoting the study through existing networks and mailing lists (including large databases of adults who had previously consented to be involved in health research across the uk), print and digital media coverage, and social media. second, more targeted recruitment was undertaken focusing on (i) individuals from a low-income background, (ii) individuals with no or few educational qualifications, and (iii) individuals who were unemployed. third, the study was promoted via partnerships with third sector organisations to vulnerable groups, including adults with pre-existing mental illness, older adults, and carers. the study was approved by the ucl research ethics committee ( / ) and all participants gave informed consent. the full study protocol, including details on recruitment, retention, and weighting is available at www.covidsocialstudy.org in this study, we focused on participants who had at least two repeated measures between st march and st may , when the uk went into strict lockdown on the rd march and remained largely in that situation until st june (although the lockdown measures started to be eased earlier in different uk nations). this provided us with data from , participants (total observations , , mean observations per person . range to ). depression during the past week was measured using the patient health questionnaire (phq- ); a standard instrument for diagnosing depression in primary care . the questionnaire involves nine items, with responses ranging from "not at all" to "nearly every day". higher overall scores indicate more depressive symptoms. anxiety during the past week was measured using the generalized anxiety disorder assessment (gad- ); a well-validated tool used to screen and diagnose generalised anxiety disorder in clinical practice and research . there are items with -point responses ranging from "not at all" to "nearly every day", with higher overall scores indicating more symptoms of anxiety. life satisfaction was measured by a single question on a scale of to : "overall, in the past week, how satisfied have you been with your life?" thirteen measures of time-use/activities were considered. these included (i) working (remotely or outside of the house), (iii) volunteering, (iii) household chores (e.g. cooking, cleaning, tidying, ironing, online shopping etc.) or caring for other including friends, relatives or children, (iv) looking after children (e.g. bathing, feeding, doing homework or playing with children), (v) gardening, (vi) exercising outside (including going out for a walk or other gentle physical activity, going out for moderate or high intensity activity such as running, cycling or swimming), or inside the home or garden (e.g. doing yoga, weights or indoor exercise), (vii) reading for pleasure, (viii) engaging in home-based arts or crafts . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint activities (e.g. painting, creative writing, sewing, playing music etc.), engaging in digital arts activities (e.g. streaming a concert, virtual tour of a museum etc.), or doing diy, woodwork, metal work, model making or similar, (ix) communicating with family or friends (including phoning, video talking, or communicating via email, whatsapp, text or other messaging service), (x) following-up information on covid- (e.g. watching, listening, or reading news, or tweeting, blogging or posting about covid- ), (xi) watching tv, films, netflix etc. (not for information on covid- ), (xii) listening to the radio or music, and (xiii) browsing the internet, tweeting, blogging or posting content (not for information on covid- ). each measure was coded as, rarely (< mins), low ( mins- hrs) and high (> hrs), except for low-intensity activities such as volunteering, gardening, exercising, reading, and arts/crafts. these were coded as, none, low (< mins) and high (> mins). we used a 'stylized questions' approach where participants were asked to focus on a single day and consider how much time they spent on each activity on the list. however, given concerns about the cognitive burden of focusing on a 'typical' day (which involve aggregating information from multiple days and averaging), we asked participants to focus just on the last weekday (either the day before or the last day prior to the weekend if participants answered on a saturday or sunday). this approach follows aspects of the 'time diary' approach, but we chose weekday to remove variation in responses due to whether participants took part on weekends . data analyses started by using standard fixed-effects (fe) models. fe analysis has the advantage of controlling for unobserved individual heterogeneity and therefore eliminating potential biases in the estimates of time-variant variables in panel data. it uses only withinindividual variation, which can be used to examine how the change in time-use is related to the change in mental health within individuals over time. as individuals are compared with themselves over time, all time-invariant factors (such as gender, age, income, education, area of living etc.) are all accounted for automatically, even if unobserved. compared with standard regression method, it allows for causal inference to be made under weaker assumptions in observational studies. however, fe analysis does not address the direction of causality. given this limitation, we further employed the arellano-bond (ab) approach , which uses lags of the outcome variable (and regressors) as instruments in a first-difference model (eq. ). the ab model uses − and further lags as instruments for − − − . the rationale is that the lagged outcomes are unrelated to the error term in first differences, − − , under a testable assumption that are serially uncorrelated. further, we treated the regressors, , as endogenous ( ( ) ≠ ≤ , ( ) = , > ). therefore, should be instrumented by − , − and potentially further lags. the ab models were estimated using optimal generalized method of moments (gmm). to account for the non-random nature of the sample, all data were weighted to the proportions of gender, age, ethnicity, education and country of living obtained from the office for national statistics . to address multiple testing, we provided adjusted p values (q values) controlling for the positive false discovery rate. these were generated by using the 'qqvalue' package . all analyses were carried out using stata v and the ab models were fitted using the user-written command, xtabond . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint demographic characteristics of participants are shown in table s in the supplement. as shown in table , the within variation accounted for about % of the overall variation for depression, and % for anxiety. anxiety explained % of the variance in depression (r= . , p<. ) and % of the variance in life satisfaction (r=- . , p<. ), while depression explained % of the variance in life satisfaction (r=- . , p<. ). there were also substantial changes in the time-use/activity variables ( figure ). over % of participants changed status in all activities, except for volunteering ( %) and childcare ( %). increases in time spent working, doing housework, gardening, exercising, reading, engaging in hobbies, and listening to the radio/music were all associated with decreases in depressive symptoms ( table , model i-i). the largest decrease in depression was seen for participants who increased their exercise levels to more than minutes per day, who increased their time gardening to more than minutes per day, or who increased their work to more than hours per day. on the contrary, increasing time spent following covid- news or doing other screen-based activities (either watching tv or internet use/social media) were associated with an increase in depressive symptoms. when examining the direction of the relationship (table , model i-ii), increases in gardening, exercising, reading, and listening to the radio/music predicted subsequent decreases in depressive symptoms. however, increases in time spent following news on covid- predicted increases in depressive symptoms, as did increases in time spent looking after children or moderate increases in communicating via videos, calling or messaging with others. increases in time spent gardening, exercising, reading and other hobbies were all associated with decreases in anxiety, while increasing time spent following covid- news and communicating remotely with family/friends were associated with increases in anxiety ( table , model ii-i). the largest decrease in anxiety was seen for participants who increased their time on gardening, exercising or reading to minutes or more per day. when looking at the direction of the relationship (table , model ii-ii), increases in gardening predicted a subsequent decrease in symptoms of anxiety. but increasing time spent following news on covid- predicted an increase in anxiety. life satisfaction increases in time spent working, volunteering, doing housework, gardening, exercising, reading, engaging in hobbies, communicating remotely with family/friends, and listening to the radio/music were all associated with an increase in life satisfaction, while increasing . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint time spent following covid- news was associated with a decrease in life satisfaction ( table , model iii-i). when looking at the direction of the relationship (table , model iii-ii), increases in volunteering, gardening and exercising predicted a subsequent increase in life satisfaction. but increasing time spent following news on covid- , working, and looking after children predicted a decrease in life satisfaction. we carried out sensitivity analyses excluding keyworkers who might not have been isolated at home in the same way and therefore might have had different patterns of behaviors during lockdown. the results were materially consistent with the main analysis (see the supplementary material). this is the first study to examine the impact of time-use on mental health amongst people during the covid- pandemic. time spent on work, housework, gardening, exercising, reading, hobbies, communicating with friends/family, and listening to music were all associated with improvements in mental health and wellbeing, while following the news on covid- (even for only half an hour a day) and watching television excessively were associated with declines in mental health and wellbeing. whilst the relationship between time use and behaviors is bidirectional, when exploring the direction of the relationship using lagged models, behaviors involving outdoor activities including gardening and exercising predicted subsequent improvements in mental health and wellbeing, while time spent watching the news about covid- predicted declines in mental health and wellbeing. our findings of negative associations between following the news on covid- and mental health echo a cross-sectional study from china showing that social media exposure during the pandemic is associated with depression and anxiety . the fact that exposure to covid- news is largely screen-based, and the fact that watching high levels of television or high social media engagement unrelated to covid- was also found to be associated with depression could suggest that this finding is more about the screens than the news specifically . however, the association with following the news on covid- was independent of these other screen behaviors and was found for even relatively low levels of exposure ( mins- hours). further, there have been wider discussions of the negative impact of news during the pandemic, including concerns about the proliferation of misinformation and sensationalised stories on social media , and information overload, whereby the amount of information exceeds people's ability to process . it is notable that these associations were found for all measures of mental illhealth and wellbeing and even in lagged models that attempted to remove the effects of reverse causality, suggesting the strength of its relationship with mental health. however, other activities were shown to have protective associations with mental health. in particular, outdoor activities such as gardening and exercise were associated with better levels of mental health and wellbeing across all measures, with many of these results maintained in lagged models. these results echo many previous studies into the benefits of outdoors activities [ ] [ ] [ ] [ ] . exercise (including gentle activities such as gardening) can . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint affect mental health via physiological mechanisms (such as reducing blood pressure), neuroendocrine mechanisms (such as reducing levels of cortisol involved in stress response), neuroimmune mechanisms (including reducing levels of inflammation associated with depressive symptoms and increasing the synthesis and release of neurotransmitters and neurotrophic factors associated with neurogenesis and neuroplasticity), and psychological mechanisms (including improving self-esteem, autonomy and mood) . particularly during lockdown, such activities (which provided opportunities to leave the home) may have helped in providing physical and mental separation from fatiguing or stressful situations at home, offering a change of scenery, and proving a feeling of being connected to something larger . hobbies such as listening to music, reading, and engaging in arts and other projects were also associated with better mental health across all measures. this builds on substantial literature showing the benefits of such activities in reducing depression and anxiety, building a sense of self-worth and self-esteem, fostering self-empowerment, and supporting resilience . the associations presented here show that these activities have remained beneficial to mental health during lockdown. however, these associations were not retained as consistently across lagged models. this suggests that they may be linked more bidirectionally with mental health, with changes in mental health also driving individuals' motivations to engage with these activities. there are several other noteworthy findings from these analyses. first, volunteering was associated with higher levels of life satisfaction, including across lagged models that explored with the direction of association, but not with other aspects of mental health. previous studies have suggested psychological benefits of volunteering, but our findings suggest that it plays a specific role in supporting evaluative wellbeing during the pandemic . second, both work and housework had some protective associations when looking at parallel changes with mental health over time. however, when looking at lagged models, housework does not appear to have been a precursor to changes in mental health, whilst frequent working was associated with lower life satisfaction, independent of other types of predictors. this echoes research highlighting working from home as a cause of stress for many people during the covid- pandemic . similarly, looking after children was not associated with changes in mental health in our main models, but increases to high volumes of childcare were associated with higher levels of depression and lower life satisfaction over time. this could reflect strain from spending substantial amounts of time on childcare or, as such increases may reflect changes in other aspects of home life such as a partner having to reduce childcare to go back to work, it could also reflect other stressors that may have in fact been driving changes in mental health. finally, communicating with family/friends had mixed effects in our main models, but when exploring the direction of association, it was in fact associated with higher levels of depression. this could be explained by data from previous studies showing that while face-to-face interactions can decrease loneliness (which is associated with mental health including depression), communication over the telephone (or other digital means) can in certain circumstances increase loneliness, perhaps as it is perceived as a less emotionally rewarding experience . this study has a number of strengths including its large sample size, repeated weekly follow-up over the weeks of uk lockdown, and robust statistical approaches being applied. however, the ucl covid- social study did not use a random sample. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint nevertheless, the study does have a large sample size with wide heterogeneity, including good stratification across all major socio-demographic groups, and analyses were weighted on the basis of population estimates of core demographics, with the weighted data showing good alignment with national population statistics and another large scale nationally representative social survey. but we cannot rule out the possibility that the study inadvertently attracted individuals experiencing more extreme psychological experiences, with subsequent weighting for demographic factors failing to fully compensate for these differences. this study looked at adults in the uk in general, but it is likely that "lock-down" or "stay at home" orders had different impact on time-use for people with different sociodemographic characteristics, for example age and gender. while our analyses statistically took account of all stable participant characteristics (even if unobserved) by comparing participants against themselves, future studies could examine how the relationship between time-use and mental health differs by individuals' characteristics and backgrounds. we also lack data to see how behaviors during lockdown compared to behaviors prior to covid- , so it remains unknown whether changes such as increasing time spent on childcare or leisure activities were unusual for participants and therefore not part of their usual coping strategies for their mental health. finally, we asked individuals to focus on the last available weekday in answering the questions on time use. whilst this has been shown to improve the quality and accuracy of recollection, it does mean that variations in time use across the entire week are not captured. finally, whilst we standardised our questions to the last week day and used the same response with all participants consistently across lockdown (which is well recognised as an approach in tracking time use, as discussed in the methods section), it is nevertheless possible that behaviors across weekends may also have been influencing mental health independent of weekday behaviors. overall, our analyses provide the first comprehensive exploration of the relationship between time-use and mental health during lockdowns due to the covid- pandemic. many behaviors commonly identified as important for good mental health such as hobbies, listening to music, and reading for pleasure were found to be associated with lower symptoms of mental illness and higher wellbeing. these results were seen when exploring parallel changes in time use and behaviors, attesting to the importance of both encouraging health-promoting behaviors to support mental health, and understanding mental health when setting guidelines on healthy behaviors during a pandemic. we also explored the direction of the relationship, finding that changes in outdoor activities including exercise and gardening were strongly associated with subsequent changes in mental health. however, increasing exposure to news on covid- was strongly associated with declines in mental health. these results are important in formulating guidance for people likely to experience enforced isolation for months to come (either due to quarantine, self-isolation or shielding) and are also key in preparing for future pandemics so that more targeted advice can be given to individuals to help them stay well at home. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: 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