key: cord-333701-zefd3yw5 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-19 pandemic challanges date: 2020-06-25 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102265 sha: doc_id: 333701 cord_uid: zefd3yw5 nan on 17th apr 2020, the chinese national bureau of statistics released news that china's economy shrank 6.8% in the first quarter of 2020 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-19 pandemic (rajkumar, 2020) , 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, 2020) . 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, 2015) . as the vicious circle of pychological distress and income inequality continues, online counseling services for people affected by the covid-19 crisis will be needed (dan, 2020) , but they may be far from sufficient (liem, sit, arjadi, patel, elhai, hall, 2020) . on top of the large pre-existing treatment gap, china might face a mental health workforce crisis. since 2010, 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 16.6% (huang, wang, wang, et al., 2019) . several steps were taken. firstly, the annual budget for all psychiatric hospitals rose from 301.324 million yuan (44.58 million usd) in 2009 to 1271.502million yuan(184.276 million usd) in 2018 with an annual growth rate of 20%. secondly, china invested a large amount of funding to improve the basic construction and facilities of psychiatric hospitals. for example, since 2009, the central government has directly invested 10.59 billion yuan (usd 1.57 billion), and the civil affairs department invested 2.8 billion yuan(usd 0.41 billion) aiming to build new or expand existing hospitals to achieve full coverage of mental health services in each prefecture-level city. consequently, from 2009 to 2018, the total number of psychiatric beds in china increased rapidly from 191,225 to 506,637, with an annual increase of 11.75% and 35.3 beds per 100,000 people, which is above the world average (who, 2018) . the number of psychiatrists increased from 18,842 in 2009 to 36,610 in 2018, at an annual rate of 7.63%; however,the number of hospital beds per psychiatrist only increased from 10.1 in 2009 to 13.8 in 2018. 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. 1. currently, there are about 2, 200 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 53,825 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 5,000 clinical psychologists, compared to the united states, which has roughly 200,000 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. 2. 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 23% of the total hospital revenue, most psychiatric hospitals have strong incentives to provide inpatient services for profit. in fact, in 2018, 97% of psychiatric services were provided in hospitals. 3. 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, 2017) . 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 20% of people with mental disorders sought advice or treatments (gbd, 2016) . low perceived need for treatment, lack of available treatments, and stigma are among barriers to care (shi, shen, wang, hall, 2020) . 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., 2018) and fear of medical violence (xiong, hu & hall, 2016; hall, xiong, chang , et al, 2018) . to reduce the burden of population' mental health caused by covid-19 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 310 diseases and injuries, 1990-2015: 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-19 epidemic ethical standards for telemental health must be maintained during the covid-19 pandemic covid-19 and mental health: a review of the existing literature barriers to professional mental health help-seeking among chinese adults: a systematic review the covid-19 pandemic, personal reflections on editorial responsibility mental health atlas 2017. 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-316461-bxcsa1h2 authors: gordon, joshua a.; borja, susan e. title: the covid-19 pandemic: setting the mental health research agenda date: 2020-05-18 journal: biol psychiatry doi: 10.1016/j.biopsych.2020.05.012 sha: doc_id: 316461 cord_uid: bxcsa1h2 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-19 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 1 . 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-19. individuals exposed to a disaster experience a wide range of reactions. in a comprehensive literature review encompassing study samples from 102 different events comprising over 60,000 individuals, norris et al. (2002) 2 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 (11%) showed minimal or highly transient impairment; half of the samples showed moderate impairment; and, the rest showed clinically significant distress (21%) or severe symptoms indicative of a diagnosable psychological disorder (18%). for most individuals exposed to disasters, the initial experience of mild and even significant symptoms tend to improve with time, but a significant minority (~10%) may have longer term or chronic experiences with mental illness 2 . 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) 2 . frontline healthcare workers treating the sick and dying may be at higher risk for experiencing psychiatric morbidity, at least acutely 3 . 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 4 . 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 5 . 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. 6 of particular concern with the covid-19 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 2001-2003 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 7 . add to these effects the potential negative impact of the economic distress that has accompanied the widespread shutdowns during covid-19, 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-19, 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 8 . delivering adequate care during disasters and other large-scale traumas is especially challenging. consider the example of hurricane katrina: 8 months after the storm, fewer than 50% of people who developed mood or anxiety disorders received any care; of those who did, 60% 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. 9 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-19 pandemic. we seek to understand the unique aspects of the covid-19 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-19 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 9/11 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-339380-1gq9wy32 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-19 patients? date: 2020-05-19 journal: the british journal of psychiatry : the journal of mental science doi: 10.1192/bjp.2020.109 sha: doc_id: 339380 cord_uid: 1gq9wy32 there is an urgent need to provide evidence-based well-being and mental health support for front-line clinical staff managing the covid-19 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-19 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-19 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-19 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. 1 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, including moral injury. this should subsequently be repeated at appropriate points such as the beginning or end of shifts. obvious covid-19 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. 2 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-19 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-19/respondingto-covid-19-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. 3 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. 4 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. 5 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-19 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-19 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 20-year longitudinal evaluation study national institute for health and care excellence. post-traumatic stress disorder (nice guideline ng116). 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/10.1192/ bjp.2020.109. key: cord-337816-ivj1imsk authors: patel, vikram title: empowering global mental health in the time of covid19 date: 2020-05-20 journal: asian j psychiatr doi: 10.1016/j.ajp.2020.102160 sha: doc_id: 337816 cord_uid: ivj1imsk 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-70s; emerging data demonstrating the vast number of asymptomatic individuals suggests the overall mortality rate is well below 1%, 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, 2008) . 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., 2018) . "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 2008 (case & deaton, 2020) . 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., 2018; singla et al., 2017) . 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., 2019; singla et al., 2014) . 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., 2017) , 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 covid19: the pushing back, once again, of mental health from the global health agenda. i recall this happening way back in the late 1990s 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 2000. 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 2020 and all funding and health care action has entirely pivoted towards one disease-covid19. 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 covid19 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-309764-nxbadlal authors: moon, katie title: understanding the experience of an extreme event: a personal reflection date: 2020-06-19 journal: one earth doi: 10.1016/j.oneear.2020.05.009 sha: doc_id: 309764 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 2020 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 200,000 km 2 and killed more than one billion vertebrates; 1 and the coronavirus disease 2019 (covid-19) 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 2019, 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-19 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. 2 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. 3 these models, which can be elicited through a variety of methods, 4 reveal how people organize and operate concepts cognitively. 5 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. 4, 6 mental models are incomplete representations of ''reality;'' they are context dependent and can therefore change over time through learning and experience. 6, 7 what has been interesting to observe during both the bushfires and the covid-19 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-19 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-19, 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-19 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-19. 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-19 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 1 ). 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. 8 importantly, the focus is on understanding the experience independently of existing knowledge, assumptions, or expectations, particularly those of the researcher. 8, 9 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. 9 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.'' 10 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. 9 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.'' 11 questions, therefore, need to account for the retrospective nature of the knowledge in exploring the mental models at the time of the experience (table 1) . a range of methods could be suitable in eliciting the mental models, including open or semistructured interviews, 2 walking interviews, 12 and even focus groups. 13 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 1) . 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. 9 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-19: 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-325844-w0zqxwdh authors: kanekar, amar; sharma, manoj title: covid-19 and mental well-being: guidance on the application of behavioral and positive well-being strategies date: 2020-09-12 journal: healthcare (basel) doi: 10.3390/healthcare8030336 sha: doc_id: 325844 cord_uid: w0zqxwdh the raging covid-19 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-19 pandemic but also in any future epidemics at the national level. covid-19 is an unprecedented pandemic affecting people all over the world. as of 29 august 2020, covid-19 (caused by the novel coronavirus) has caused 5,845,876 cases and 180,165 total deaths in the united states [1] and 24,257,989 cases and 827,246 deaths worldwide [2] . 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 [3] . the covid-19 pandemic with its uncertainty has imposed great mental distress on the general public, its patients, and healthcare providers [4] . the pandemic and its constant reporting in the media have increased distress-related psychological problems such as anxiety, depression, and insomnia [5, 6] . at present, there is no established treatment for covid-19 or any vaccine for specific protection against it. the testing for covid-19 is not widely available and lacks desirable sensitivity and specificity [7, 8] . 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 (1) isolation in which infected persons are separated from non-infected individuals; (2) quarantine and fever surveillance of contacts who have been exposed but are not yet symptomatic; (3) 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) [9] . 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 [10, 11] . the fear associated with this pandemic is responsible for the activation of the hypothalamuspituitary-adrenal (hpa) axis [12] . 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 [13] . all these effects eventually drain the body's energy resources in the long run and also compromise immunity and mental resilience [14] . although the centers for disease control and prevention (cdc) have provided some guidelines to reduce stress and initiate coping [9] , 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 [15] . mental health denotes emotional, psychological, and social well-being [16] . 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 [17, 18] . 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 [19] will be explored, particularly from its applicability to the current covid-19 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 [19] . 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 [20] . 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. [21, 22] . for example, the student population has greatly benefitted from a mindfulness course in terms of improved well-being, decreased stress, and increased resilience [23] . similar benefits were noted in diverse populations such as older adults [24] , adolescents [25] , and educators [26] . a systematic review [27] and another meta-analysis [28] 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 [29] . social connections (some of which are explained later) have shown proven associations between long-term well-being [30] [31] [32] , 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 [33, 34] . 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 [35] 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 [34] . 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 [35] . there are several determinants of positive mental health such as hardiness, sense of coherence, social support, optimism, and self-esteem [36] that are important in the context of covid-19. according to the hardiness theory [37] , 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-19, 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-19, 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-19 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-19 is the sense of coherence theory [38, 39] . 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-19, 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-19, 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-19-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-19 pandemic is that of social support, which is the help obtained through social relationships [40, 41] . social support was classified into four kinds: (1) emotional support that requires the provision of understanding, caring, love, and fosters reliance; (2) informational support that requires the provision of information, counsel, and guidance; (3) instrumental support that requires the provision of tangible help; (4) appraisal support that provides evaluative help. during these times of covid-19 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 [42] , which requires one to expect the best possible outcome in any situation and is a learned behavior [43] . optimism, in the covid-19 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 [44, 45] . 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-19 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-19 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 [46] . fortunately, this anxiety can be measured [47] 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 [48] , emerging research suggests the role of positive self-talks and cognitive behavior therapy as effective modalities to modify or attenuate the 'death anxiety' [49, 50] . thought interference, particularly annoying thoughts related to fear of death due to covid-19 can be very disturbing for individuals, and these strategies promote the 'problem-centered' coping style [51] for stress reduction and, along with the behavioral strategies mentioned earlier, could be highly effective. the covid-19 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-19 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-19 pandemic, and how the constructs of these theories could be modified to enhance mental health and well-being among covid-19 affected individuals. social support theory-based constructs could be utilized in developing and implementing interventions in preventing and promoting mental health in covid-19 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 2019: cases in the us rolling updates on coronavirus disease (covid2019) covid 19 and its mental health consequences public mental health crisis during covid-19 pandemic progression of mental health 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subjective well-being in the english longitudinal study of ageing greater good science center a meta-analytic review of the relationship between dispositional gratitude and mental well-being. personal how does trait gratitude relate to subjective well-being in chinese adolescents? the mediating role of resilience and social support the resilience workbook: essential skills to recover from stress, trauma and adversity foundations of mental health promotion personality and resistance to illness unraveling the mystery of health: how people manage stress and stay well social support and health optimism, coping, and health: assessment and implications of generalized outcome expectancies learned optimism. how to change your mind and life measures of self-esteem society and the adolescent self-image incremental validity of coronaphobia: coronovirus anxiety explains depression, generalized anxiety and death anxiety measuring anxiety related to covid-19: a turkish validation study of the coronavirus anxiety scale. death stud looking after our mental health the role of self-talk in predicting death anxiety death anxiety in the time of covid-19: theoretical explanations and clinical implications disease perception and coping with emotional distress during covid-19 pandemic: a survey among medical staff key: cord-348411-nrhe8aek authors: shah, kaushal; mann, shivraj; singh, romil; bangar, rahul; kulkarni, ritu title: impact of covid-19 on the mental health of children and adolescents date: 2020-08-26 journal: cureus doi: 10.7759/cureus.10051 sha: doc_id: 348411 cord_uid: nrhe8aek the coronavirus disease 2019 (covid-19) 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 18th, 2020, the coronavirus had spread to more than 216 countries with at least 21,756,357 confirmed cases, resulting in 771,635 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 67.6% of students are impacted globally due to coronavirus in 143 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 2019, the outbreak, now known as covid-19, has spread globally [1] . the world health organization (who) acknowledged this coronavirus epidemic as a pandemic and declared the outbreak as a public health emergency of international concern [2-3]. 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 [3 -4] . as of august 18th, 2020, the coronavirus had spread to more than 216 countries and has at least 21,756,357 confirmed cases, resulting in 771,635 confirmed deaths globally. in the united states, between january 20th and august 18th, 2020 , there have been 5,354,013 confirmed cases of covid-19 with 168,999 deaths [5] . the spread of the virus has caused global economic and social disruptions and has brutally overwhelmed the healthcare and educational systems [6] . 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 [7] . mental disorders are the leading cause of disability worldwide in adolescents and children. about 15% of children and adolescents in the world have mental health disorders or conditions. nearly 50% of mental disorders start to affect the children by the age of 14. 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 [8] . 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 2016, an estimated 53,000 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 [9] . as of august 18th, 2020, 143 countries have closed schools and educational facilities worldwide due to the covid-19 pandemic, impacting 1,184,126,508 learners, consisting of about 67.6% of students globally. it has forced several countries to implement home-based learning or online training [10] [11] [12] . approximately 1.1 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 [10] . 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 [11] [12] . the conducted literature search was through medline, pubmed, pubmed central, and embase using the keywords, 'coronavirus,' 'covid-19,' '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 1. to understand the overall psychological impact of covid-19 on children and adolescents; 2. identifying factors contributing adversely to their mental health; and 3. proposing interventions based on the guidelines and evidence-based practices. the outbreak of covid-19 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 [13] . children exposed to these incidents can precipitate the development of anxiety, panic attacks, depression, mood disorders, and other mental illnesses [11] . 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-19, 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 [14] . covid-19 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 [15] . 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-19 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 25% of the patients showed signs of post-traumatic stress disorder (ptsd), and 15.6% of them had worsening depression [16] . this finding corresponds to the increased suicide deaths among sars survivors, consisting of older adults from hong kong in 2003 and 2004 [17] . among those mers survivors, lower quality of life was also noticed. neuropsychiatric linkage has been established based on the previous outbreaks [18] . 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 [11] . 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 [15] . 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 [19] . 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-19 settings, and others have parents who now work from home or have recently been terminated [19] . 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 [19] [20] . 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 [20]. the covid-19 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 [21] . 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 [22] . the health organization has also emphasized maintaining better hygiene by consistently washing hands and using appropriate protective gear such as facial masks [22] . 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 [22] . 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 [23] . 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 [24] [25] . 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-19 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 [24] . 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 [26] . 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 [26] . 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 [27] [28] . comprehensive school mental health systems (csmhss) is required to deliver adequate assistance for the students effectively [27] . 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 [27] . 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-19; and to stabilize any previously diagnosed mental illness or prevent new mental illness from developing [27, 29] . 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-19 through several sources, such as the evening news [29] [30] . 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-19 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-19 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 [27] . not only can parents inform children about quarantine, but they can also employ "positive parenting" [31] . 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 [31] [32] . while parents can provide a deeper understanding of the covid-19 and quarantine, school systems can provide further reassurances and educate children about emotions [33] . 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 [34] . furthermore, school systems must adapt to the new online learning method and help students adjust and thrive in online classes [34] [35] . 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 [31] [32] . 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 [27] . 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 [31, 35] . the epidemiology and clinical information about covid-19 covid-19 strategy update children's mental health child and adolescent mental health adolescent mental health empowering students with disabilities during the covid-19 crisis covid-19 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-19 crisis poses threat to financial stability focus on mental health during the coronavirus (covid-19) 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-19 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-19) 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-19 psychological interventions during covid-19: 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-19: a rapid systematic review key: cord-348298-rtm8dn43 authors: o’connor, karen; wrigley, margo; jennings, rhona; hill, michele; niazi, amir title: mental health impacts of covid-19 in ireland and the need for a secondary care mental health service response date: 2020-05-27 journal: irish journal of psychological medicine doi: 10.1017/ipm.2020.64 sha: doc_id: 348298 cord_uid: rtm8dn43 the covid-19 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, 2008; shultz et al. 2013; health service executive, 2014) . the covid-19 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. 1 ). 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 14 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-19 pandemic are illustrated in fig. 1 . 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. 1 ). 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-19 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-19 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-19 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-19, 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 1 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, 2020) . 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-19. 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-19 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-19 health service utilization reluctance to attend for acute care due to fears of covid-19 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-19 in ireland 3 illness. it was estimated that 50% of family members of sars patients experienced psychological problems (mainly depressive symptoms) and stigmatisation (tsang et al. 2004) . 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. 2009 ). a study of 549 healthcare workers in beijing, china, 3 years after the sars epidemic found that 10% continued to experience high levels of posttraumatic stress (wu et al. 2009 ). 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. 2020) . 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. 2015) . 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-19, 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-19. this is especially the case if they are aware of the deaths of fellow residents from covid-19. young people (aged 15-25) 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. 2014 ; union of students of ireland, 2019). 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. 2019) . 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 2 in 2019, a self-report survey, showed that the already high rates of depression, anxiety and self-harm in young people reported in my world survey 1(2012) had risen even further (dooley, 2019) . irish youths have the fourth highest suicide rate in europe (unicef, 2017). 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. 2019). some individuals with intellectual disability live in congregated settings. such settings may be more vulnerable to covid-19 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-19 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-19, 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-19, 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-19 pandemic (see table 2 ). 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. 2018) . risk factors associated with poorer outcomes in covid-19 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. 2020) . funding of mental health services in ireland has remained consistently low,~6% of the overall health budget (compared to 12% in new zealand and united kingdom) (college of psychiatrists of ireland, 2020). ireland has the third lowest number of psychiatric beds in europe (eurostat, 2017). 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 2019 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 57%, 61% and 33%, 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, 2017). 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-19 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 30% of young people who present (headspace australia) have needs that are in excess of what can be managed there (rickwood et al. 2019) . 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, 2017) . mental health impacts of covid-19 in ireland 5 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-19 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-19 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, 2020) . trauma and social marginalisation are risk factors associated with longer term increased risk of psychosis (radua et al. 2018) . 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-19. 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-19. 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-19 (alvarez-jimenez et al. 2015) . 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-19 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-19, 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 11975, as revised in 2008. 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-19 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-19 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 mental health and social change in the time of national youth mental health taskforce psychosocial care for people affected by disasters and major incidents: a model for designing, delivering, and managing psychosocial services for people involved in major incidents, conflict, disasters and terrorism what causes psychosis? an umbrella review of risk and protective factors suicide mortality and coronavirus disease 2019-a perfect storm australia's innovation in youth mental health care: the headspace centre model integrated care to address the physical health needs of people with severe mental illness: a mapping review of the recent evidence on barriers, facilitators and evaluations psychological impacts of natural disasters psychosocial impact of sars (letter) building the future: children and the sustainable development goals in rich usi national report on student mental health in third level education. union of students in ireland the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception and altruistic acceptance of risk key: cord-326574-ke0iktly 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-19 date: 2020-09-09 journal: front psychiatry doi: 10.3389/fpsyt.2020.582007 sha: doc_id: 326574 cord_uid: ke0iktly nan the coronavirus disease 2019 (covid-19) pandemic has had an immense impact infecting 10 million individuals and claiming 500,000 lives globally as of 1 july 2020 (1) . 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 (2) . 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 (3, 4) . notably, emotionally driven sharing of misinformation has featured prominently in this crisis, fueling both confusion and irrational anxiety among the public (5, 6) . 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 (7) . 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 (8) . the psychosocial impact of large-scale disasters and previous outbreaks have been described, including increased incidence of mental health disorders (9) . similarly, covid-19 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 (4, 10) . 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 (10) (11) (12) . 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 (9, 11) . fortunately, several reports have demonstrated the effectiveness of digital health solutions for various applications, including addressing gaps in mental health services (12) . 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 (13, 14) . 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 (15) , queries in online search engines (16) , and even connected devices among the internet of things (iot) such as mobile phones and drones (17, 18) . 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 (19, 20) . successful applications include monitoring dengue outbreaks using data on mobility from mobile phones (15) or queries in search engines such as baidu in china (21) . 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-19 based on historic travel data and public health capacity (22) . also, cornelia betsch and the covid-19 snapshot monitoring (cosmo) group evaluated methods for surveillance of behavioral responses to the pandemic (5). these applications enable evidence-based approaches to localize public health responses and monitor their effectiveness, in accordance with who recommendations (23) . related applications for mental health include the prediction of disorders such as depression, stress and anxiety, using publicly available data from websites like twitter (24) . 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 (24, 25) . 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 (26) . this ushers in the possibility of precision digital mental health with tailored recommendations to the individual, as recently described for panic disorder (27) . 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 (28) . measures to facilitate implementation include the use of high quality input data and clinical validation using formal diagnostic criteria, robust methodology, and actionable outcomes (29) . 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 (9) . 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 (30) . preliminary reports of ai chatbots that have been developed for mental health include solutions providing counseling for well individuals to improve psychological wellbeing (31) . others include ai chatbots such as wysa for digital mental well-being with demonstrated effectiveness in patients with depression (32), and woebot for cognitive behavioral therapy (cbt) in young adults with depression/anxiety symptoms (33) . 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 (30) . however, their applications needs to be supervised given limited clinical validation with robust experimental design (34) . other challenges clinical ai have also been described in various specialities, including practical, technical, and sociocultural barriers to implementation (35, 36) . 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 (37) . this is crucial to ensure emotional support or triage advice are perceived accurately by patients, and piloting messages will help ascertain effectiveness (38) . 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 (39) . 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 (9) . 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 (12, 40) . 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 (8) . 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 (38) . however, due to the speed of misinformation propagated online, there is increasingly a need to implement a digital effector arm for our monitoring systems (3), one that amplifies reputable sources to directly combat misinformation in a transparent, scalable manner by addressing myths and promoting reputable sources of information (41) . in singapore, such a solution was developed by askdr through needs-finding surveys and ideation with frontline providers (figure 1 ). 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 (42) . 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 (43) . 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 (28) . 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 (44) . 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 (9). 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 (45) . these can be used for either asynchronous or synchronous consultations with private discussions between patients and healthcare providers (46) . existing descriptions of tele-mental health services indicate the importance of human support and interaction regardless of the embodiment of telehealth used (6, 12) . although its application in covid-19 for mental health services has been greatly enabled by legislative changes (6), the barriers to telehealth adoption that have kept it from becoming mainstream to date still remain (47) . ensuring successful, sustained adoption requires active alignment with clinical needs when deploying services (6) . 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 (9) . 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 (11, 48, 49) . 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 (50) and is mainstreamed in countries like singapore to project tertiary care to nursing homes and intermediate and long-term care (iltc) facilities. covid-19 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 (4, 11) these unprecedented challenges highlight the need to develop creative solutions to address the impending surge in mental health disorders (4, 10) . 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 (51) . 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 (52) . 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 (52) . 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 (49) . 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 (3, 16) . 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 (4, 53) . 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 (35, 36) . deployment of digital health thereby needs to be driven by the needs of the target patient population, clinical acceptance, and validated effective applications (38) . 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 (35, 38) . 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 (38) . meeting the needs of patients in a timely and cost-effective manner ensures sustained adoption beyond the covid-19 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 (6) and are just as important for other forms of digital health (47) . 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 (51), as well as develop solutions with targeted applications such as ai chatbots for automated adolescent mental health coaching (54) . 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 (9) . 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-19 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 (6, 47) . 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 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type and chew et al. digital health for "viral" pandemics frontiers in psychiatry | www coronavirus covid-19 singapore internet use and stigmatized illness advantages and limitations of online communities of patients for research on health products the role of telehealth in the medical response to disasters next generation telemedicine platforms to screen and triage telehealth for global emergencies: implications for coronavirus disease 2019 (covid-19) motivational interviewing approach used by a community mental health team telehealth home support during covid-19 confinement for community-dwelling older adults with mild cognitive impairment or mild dementia: survey study the use of remote presence for health care delivery in a northern inuit community: a feasibility study safety and efficacy of follow-up for patients with abdominal pain using video consultation (saved study): randomized controlled trial evaluating digital telereview illness management and recovery program for mental health problems: reducing symptoms and increasing social functioning cognitive processing therapy for posttraumatic stress disorder via telehealth: practical considerations during the covid-19 pandemic a chatbot-based coaching intervention for adolescents to promote life skills: pilot study key: cord-310677-begnpodw authors: yeasmin, sabina; banik, rajon; hossain, sorif; hossain, md. nazmul; mahumud, raju; salma, nahid; hossain, md. moyazzem title: impact of covid-19 pandemic on the mental health of children in bangladesh: a cross-sectional study date: 2020-07-29 journal: child youth serv rev doi: 10.1016/j.childyouth.2020.105277 sha: doc_id: 310677 cord_uid: begnpodw covid-19 pandemic poses a significant mental health threat among children in bangladesh. this study aims to explore the impact of covid-19 on the mental health of children aged<15 years during the lockdown in bangladesh. an online cross-sectional study was conducted from 25th april to 9th may 2020 among 384 parents having at least one child aged less than 15 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 43% of child had subthreshold mental disturbances (mean major depressive disorder (mdd)-10; 2.8), 30.5% had mild (mean mdd-10; 8.9), 19.3% suffered moderately (mean mdd-10; 15.9), and 7.2% of child suffered from severe disturbances (mean mdd-10; 25.2). the higher percentage of mental health disturbances of children with the higher education level of parents, relative infected by covid-19 (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 2019 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 14 million people around the globe with at least 5,97583 deaths as of july 19, 2020 (world health organization, 2020a . to halt the covid-19 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, 2020) and classes are shifted to home-based distance-learning models (golberstein et al., 2020) . 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., 2020) . 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, 2020; galvin, 2020; rawstrone, 2020) . to prevent the outbreak of covid-19, bangladesh have been closed the academic institutions, therefore, about 3.7 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, 2020) . 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., 2017) . 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., 2017) . 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., 2020) . to assess the impact of home quarantine on children's mental health, a study was performed among 1,800 chinese children and identified that one in five children (20 percent) in china was either suffering from depression or anxiety, or both (dunleavy, 2020) . also, mental health issues remain fairly elevated among u.s. children due to the covid-19 pandemic. according to the centers for disease control and prevention, 4.4 million children between the ages of 3 to 17 years have been diagnosed with anxiety and 1.9 million have been identified with depression because of home quarantine due to . moreover, about three in four children having depression along with anxiety (galvin, 2020) . the effect of the covid-19 pandemic on children's mental well-being is worrying 60% of parents, according to a survey by parents with primary-aged children and 87% 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, 2020) . in bangladesh, as the number of covid-19 cases continues to rise thus an immediate public health response is urgently needed (banik et al., 2020) . consequently, the government of bangladesh enforced full lockdown and all schools were closed from may 17, 2020 (kamruzzaman & sakib, 2020) , which negatively impact children's wellbeing through interruption of their health care, nutrition, security, education, and overall mental health (joining force bangladesh, 2020). yet, there is no literature available in bangladesh on the long-term impact of covid-19 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-19 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 25 th april to 9 th may, 2020 after completing 30 days of home-quarantine following lockdown declaration on 26th march 2020 by the government of bangladesh (world health organization, 2020b). 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 5-15 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 = 1.96 and d = 0.05 confidence interval as 0.05. the sample proportion was assumed as 0.5 since this value provide the maximum sample size. hence, the required sample size was 384. however, a total of 387 respondents completed the survey and after cleaning the incomplete responses 384 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 40 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 5-15 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-19, 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 47-item revised child anxiety and depression scale (rcads) (chorpita et al., 2000) includes the 10-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., 2004) . also, gad6 is a 6-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, 1983) , a questionnaire to assess children's behavior/emotional problems at ages of 5-15 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-10 and gad-6 scales are evaluated at 4-points (0=never, 1= once in a week, 2= 2-4 times in a week, & 3= everyday) which gives a total score of 0 to 30 and 0 to 18 respectively. moreover, sds-6 used a 3-point scale (0=not true; 1=sometimes true; 2=very true/often true) which gives a total score of 0 to 12. 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 0.814 which is more than the acceptable value of 0.70. 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., 2020 ) 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, 1998) . the significance level is set at a p-value<0.05 here. data analysis is performed using ibm spss among the participants, there are 157 (40.9%) female and 227 (59.1%) male respondents. the majority of the participants tended to be aged 36-45 years (46.6%), had an educational level of post-graduation (35.4%), and lived in the urban areas (63.3%). a total of 56.3% of the respondents were involved in a job during the lockdown, where 25.3% of participants needed to go to the table 1 ]. [ table 1 here] the depression, anxiety, and sleeping disorder scores of children were classified into 4 groups (sub-threshold, mild, moderate, and severe disturbance) using k-means clustering. results depict that 43% of child had subthreshold mental health disturbances (mean depression: 2.8, anxiety: 2, and sleeping disorder: 1), 30.5% had mild disturbances (mean depression: 8.9, anxiety: 4.9, and sleeping disorder: 3), 19.3% suffered from moderate disturbances (mean depression:15.9, anxiety: 9.2, and sleeping: 6), and 7.2% suffered from severe disturbances (mean depression: 25.2, anxiety: 13.4, and sleeping disorder: 8). 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 2 . [ table 2 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 8 family lived in the urban areas (63.3%). the child had higher mental health disturbance scores who had higher corona positive relative/ neighbor [ table 3 ]. [ table 3 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 (25%), had a smoking habit (35.7%) and had the chance of losing their job (28.6%) 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 2-4 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 3 ]. the average score of depression, anxiety and sleeping disorder by different groups are presented in figure 1 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 1 here] the chi-square test of the model fit yielded a value of 151.890, with degrees of freedom=84, p-value< . the results of chi-square test, rmsea = 0.046, cfi = 0.954, and tli= 0.942 0.001 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 2 and table 4 . [ table 4 here] [ figure 2 here] mental health is an essential part of any country and ignored particularly in low and middle-income countries (patel, 2007) . 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 26 to 45 years and most of them were living in the urban areas and majorities are males ( table 1 ). 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 (43%), and 30.5% had mild disturbances, 19.3% had moderate disturbances, and 7.2% had severe disturbances ( table 2 ). the education level of parents of children, place of living, relatives/neighbors infected with covid-19, 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 3) . 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, 2020). on the contrary, children in rural areas are free to move and can play with their relatives/friends (ranscombe, 2020) . 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, 2020). 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, 2009 ). 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, 2009 ). 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., 2004) . 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., 2019) . 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 3 ). 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, 2014) . 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, 2014) . 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., 2020) . the findings of this study also showed that parental depression and smoking behavior also linked to child mental disorder ( table 3) . the children's mental depression was relatively low who was busy with some works as compared to who was not ( table 3) , which is very usual. engaging with some works or encouraging daily exercise will help children to reduce depression (hurley, 2020) . 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., 2007) . 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., 2015) . 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., 2013) . 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 participants also provide their consent for publishing the analyzed results of this survey without their identifiable information. this study was carried out online in full conformity with the provisions of the helsinki declaration on human participant research. manual for the child behavior checklist : and revised child behavior profile managing schools, learning and student wellbeing during covid-19. the daily star lockdown in the context of bangladesh covid-19 and bangladesh: challenges and how to address them covid-19 in bangladesh: public awareness and insufficient health facilities remain key challenges understanding differences between summer vs . school obesogenic behaviors of children : the structured days hypothesis the psychological impact of quarantine and how to reduce it : rapid review of the evidence parents' employment and children's wellbeing. the future of children assessment of symptoms of dsm-iv anxiety and 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mediating effects of children's cognitive vulnerabilities working mothers: how much working, how much mothers, and where is the womanhood? covid-19: we can ward off some of the negative impacts on children rural areas at risk during covid-19 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-19 outbreak coronavirus disease (covid-19) covid-19 key: cord-326693-tbv1yja9 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-19 pandemic date: 2020-11-03 journal: int j ment health addict doi: 10.1007/s11469-020-00416-8 sha: doc_id: 326693 cord_uid: tbv1yja9 maintaining positive mental health can be challenging during the covid-19 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 392 (70.9% female) undergraduate students, ranging in age from 18 to 43 years (m = 20.67 years, sd = 3.66) and they have predominantly been imposed stay-at-home orders for coronavirus right after announcement of covid-19 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-19. 2020; spiker and hammer 2019; tanhan 2019) . mental well-being, on the other hand, includes the presence of fulfillment with emotional, social, and psychological experiences (keyes 2014; seligman and csikszentmihalyi 2000; smith et al. 2020) . the absence of mental illness does not completely reflect the presence of well-being or vice versa (keyes 2014). researchers suggested the continuity of mental health to describe one's fully functioning in social, emotional, and psychological domains (diener et al. 1999; keyes 2014) . 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 2001) . complete mental health is linked to coping, self-esteem, optimism, psychological flexibility, feeling of control, resilience, functioning, and adjustment (arslan 2018; arslan and allen 2020; bieda et al. 2017; keyes 2002; keyes 2005 ; moore and diener 2019; peterson and seligman 2004) . well-being typically refers to "optimal psychological functioning and experience" and is a multidimensional construct including hedonic and eudaimonic dimensions (ryan and deci 2001) . 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 1995; ryff et al. 1999) . although swb and pwb are conceptually overlap to some extent, they are empirically distinct concepts (ryan and deci 2001) . 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. (2005) 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 2017; huang and humphreys 2012; kansky and diener 2017) , and self-productivity, success, subjective vitality, meaning, self-esteem, and marital satisfaction (akdağ and cihangir-çankaya 2015; braaten et al. 2019) . given that the perception of meaning in life and mental health of individual may be adversely affected during difficult times like the covid-19 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 392 (70.9% female and 29.1% male) undergraduate students attending a public university in an urban city of turkey. they ranged in age from 18 to 43 years (m = 20.67 years, sd = 3.66). the unique characteristic of the participants is that 68% of them were under 20 years old who have been imposed stay-at-home orders for coronavirus right after announcement of covid-19 restrictions. most of them considered themselves at medium-risk for coronavirus (low = 31.3%; medium = 60.9%; high = 7.7%). 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 6-item self-report measure that is scored based on a 7-point likert-type scale from strongly disagree (1) to strongly agree (7) (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 2020b) . the scale had also a strong internal reliability estimate with the current sample (α = .82). psychological distress brief symptom inventory (bsi-18) was used to measure mental health difficulties of individuals (derogatis and fitzpatrick 2004) . the scale is an 18-item self-report questionnaire and includes three 6-item subscales: depression, anxiety, and somatization (e.g., "pains in heart or chest," "feeling no interest in things"). all items are responded using a 5-point likert-type scale, ranging from not at all (0) to very much (4). although psychometrics of the previous versions (scl-90 and bsi-53) 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-18 was investigated using the sample of this study. confirmatory factor analysis results, which structured the 18 observed bsi items as indicators of three subscales, indicated that the measurement model yielded adequate datamodel fit statistics (χ 2 = 414.99, df = 130, p < .001, tli = .90, cfi = .92, rmsea [90% ci] = .075). factor loadings of the scale were strong ranging from .49 to .85 (somatization λ range = .57-.74; depression λ range = .49-.85; anxiety λ range = .50-.79; covariance = 3-11 items and 16-17 items), and internal reliability coefficients (overall bsi-18 α = .93; somatization α = .84; depression α = .83; anxiety α = .86). these results provided good evidence for a three-factor model of the bsi-18 that could be used to measure psychological distress among young adults. positive mental health mental health continuum short form (mhc-sf) is a 14-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. 2008 ). all items are scored using a 6-point likert scale, ranging between never (0) and almost (5). previous research has provided evidence supporting good psychometric properties in different cultures (keyes et al. 2008; petrillo et al. 2015) including turkish culture (demirci and ahmet 2015) . the scales had also strong internal reliability estimate with the present sample (α range = .83-.88, see table 1 ). subjective well-being the scale of positive and negative experience (spane) (diener et al. 2010 ) and the satisfaction with life scale (swls) (diener et al. 1985) were combined to measure individuals' subjective well-being. the spane is a 12-item self-report questionnaire used to assess individuals' emotions and moods and includes two 6-item subscales: positive feeling experience (e.g., "pleasant," "good") and negative feeling experience (e.g., "unpleasant," "negative"). all items are rated on a 5-point likert scale, ranging from very rarely or never (1) to very often or always (5). research indicated that the scale had good psychometric properties and strong internal reliability estimates for turkish samples (telef 2013) . the swls was also used to assess individuals' cognitive assessments of well-being. the scale is a 5-item self-report instrument (e.g., "the conditions of my life are excellent") that is answered using a 7-point likert-type scale, ranging from strongly agree (7) to strongly disagree (1). previous research showed that the reliability coefficients of the swls were adequate for turkish sample (dağlı and baysal 2016) . the internal reliability estimate of the scale was strong in the present study (α range = .77-.90, see table 1 ). 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 (6 participants), skewness and kurtosis scores were used to investigate the normality assumption, and the estimates ≤ |3| were considered as adequate for normality (d'agostino et al. 1990; kline 2015) . 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 2 ), with traditional decision rules: .01-.059 = small, .06-.139 = moderate, ≥ .14 = large (cohen 1988) . 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 ≥ .90 were considered an adequate data-model fit; the root mean square error of approximation (rmsea; with 90% ci) values between .05 and .08 were viewed as a good data-model fit (hooper et al. 2008; hu and bentler 1999) . furthermore, multi-group analysis was conducted to investigate gender differences on the study variables. all statistical analyses were performed using spss version 25 and amos version 24. findings from descriptive analysis showed that skewness and kurtosis scores ranged between − 1.52 and 3.43, suggesting that all variables provided relatively normal distribution (d'agostino et al. 1990; kline 2015) . internal reliability estimates of the study variables were adequate-to-strong, ranging from .77 to .90, as shown in table 1 . 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 = .58, p < .001), positive feelings (r = .42, p < .001), and emotional (r = .46, p < .001), social (r = .50, p < .001), and psychological well-being (r = .61, p < .001), ranging from moderate to large effect sizes. meaning in life had also significant and negative correlations with negative feelings (r = − .23, p < .001), somatization (r = − .30, p < .001), depression (r = − .47, p < .001), and anxiety (r = − .32, p < .001), ranging from small to large effect sizes, as shown in table 2 . 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 2 = 153.39, df = 54, p < .001, rmsea = .069 [90% ci .58-.82], cfi = 97, and tli = .93). standardized regression estimates indicated that meaning in life significantly and moderately-to-largely predicted subjective well-being components, ranging from .06 to 41 effect sizes: life satisfaction (β = .64, t = 11.80, p < .001), positive feeling (β = .45, t = 8.20, p < .001), and negative feelings (β = − .24, t = − 4.28, p < .001). subsequently, meaning in life had significant and strong predictive effects on positive mental health indicators, ranging from .25 to 44 effect sizes: emotional (β = .50, t = 9.18, p < .001), social (β = 54, t = 9.82, p < .001), and psychological well-being (β = 66, t = 12.21, p < .001). lastly, findings of the study indicated the significant and large predictive effects of meaning in life on student psychological difficulties, ranging from .11 to 26 effect sizes: somatization (β = − .33, t = − 5.95, p < .001), depression (β = − .51, t = − 9.40, p < .001), and anxiety (β = − .35, t = − 6.41, p < .001), see table 1 and fig. 1 . 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 2 = 264.72, df = 108, p < .001, rmsea = .061 [90% ci .52-.70], cfi = 95, and tli = .90). 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 3 . 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-19 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-19 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-19, and maintain their mental health. (rosenberg 2020) . 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. 2005) . 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-19 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. 2012; galang et al. 2011; santos et al. 2012; yıldırım and güler 2020b) . arslan and allen (2020) 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. (2012) found that meaning in life was positively related to positive emotion and life satisfaction and negatively associated with negative emotions. cohen and cairns (2011) 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. 2013; garcía-alandete 2015; garcía-alandete et al. 2018; mulders 2011) . meaning in life significantly predicted psychological well-being (garcía-alandete 2015; garcía-alandete et al. 2018) . 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. 2013) . 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 2012; mascaro and rosen 2005, 2008; steger et al. 2009 ). for example, hedayati and khazaei (2014) 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 2012). 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-19 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 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relation between meaning in life and psychological well-being publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-346310-venpta28 authors: filgueiras, a.; stults-kolehmainen, m. title: factors linked to changes in mental health outcomes among brazilians in quarantine due to covid-19 date: 2020-05-16 journal: nan doi: 10.1101/2020.05.12.20099374 sha: doc_id: 346310 cord_uid: venpta28 the 2020 covid-19 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 = 360, 37.9 years of age, 68.9% female) were surveyed at the start of quarantine and 1 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-19 related risk factors, such as perceived risk of covid-19, information overload, and feeling imprisoned. overall, all mental health outcomes worsened from time 1 to time 2, although there was a significant gender x time interaction for stress. 9.7% of the sample reported stress above the clinical cut-off (2 sd above mean), while 8.0% and 9.4% were above this cutoff for depression and anxiety, respectively. in repeated measures analysis, female gender, worsening diet and excess of covid-19 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 (0 days/week > 6 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-19 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 2020 covid-19 pandemic is a crisis of global proportions with a significant impact on the 23 country of brazil. the aims of this investigation were to track changes and risk factors for mental 24 health outcomes during state-mandated quarantine. adults residing in brazil (n = 360, 37.9 years 25 of age, 68.9% female) were surveyed at the start of quarantine and 1 month later. outcomes 26 assessed included perceived stress, state anxiety and depression. aside from demographics, 27 behaviors and attitudes assessed included exercise, diet, use of tele-psychotherapy and number of 28 covid-19 related risk factors, such as perceived risk of covid-19, information overload, and 29 feeling imprisoned. overall, all mental health outcomes worsened from time 1 to time 2, 30 although there was a significant gender x time interaction for stress. 9.7% of the sample reported 31 stress above the clinical cut-off (2 sd above mean), while 8.0% and 9.4% were above this cutoff 32 for depression and anxiety, respectively. in repeated measures analysis, female gender, 33 worsening diet and excess of covid-19 information was related to all mental health outcomes. 34 changes in diet for the worse were associated with increases in anxiety. exercise frequency was 35 clearly related to state anxiety (0 days/week > 6 days/week). those who did aerobic exercise did 36 not have any increase in depression. use of tele-psychotherapy predicted lower levels of 37 depression and anxiety. in multiple regression, anxiety was predicted by the greatest number of 38 introduction 44 mental health comprises the set of emotions, thoughts and behaviours that enable individuals to 45 work, cope and deal with problems in everyday tasks (who, 2004) . historically, although 46 researchers from the biomedical sciences dedicated more time and resources in the study of 47 physical health, findings from the last 50 years have slowly captured the interest of scientists 48 from diverse fields to look upon mental health to explain somatic diseases, physical functioning, 49 quality-of-life, well-being and work productivity, (christensen et al., 1999; prince et al., 2007; 50 stults-kolehmainen, tuit & sinha, 2014) . for instance, mental health is associated with 51 disability-adjusted life years (dalys) and premature mortality (vigo, kestel, pendakur et al., 52 2019) with 17% of dalys attributable to mental health in brazil and 22% in the united states. 53 those with worse mental health, such as higher levels of chronic stress, have a greater risk for 54 physical health problems, such as cardiovascular disease (stults-kolehmainen, 2013). poor 55 mental health costs society a great deal of money, in terms of lost productivity, strain on 56 healthcare systems, loss of income and other consequences (trautman, rehm, wittchen, 2016). 57 on the other hand, recent research from the world health organization suggests that every one 58 american-dollar spent in mental health care is equivalent to a return of four american-dollars in 59 better well-being and ability to work (who, 2016).thus, a person who has good mental health 60 entails someone who is physically healthy, happy and productive for themselves and the greater 61 functioning of society (prince et al., 2007; who, 2016) . 62 the recent outbreak of the corona virus disease 2019 (covid-19 or sars-cov-2) around the 63 world at the end of 2019 and the beginning of 2020 led to a series of guidelines to avoid mass 64 contamination and limit its lethality (who, 2020). among these recommendations are 65 quarantine, confinement and social distancing (wilder-smith & freeman, 2020). these 66 impositions mean that people cannot walk freely from their homes; they need to keep a 2-meter 67 physical distance from one another on the streets and sick people are obliged to be confined in 68 hospitals or their own homes without any kind of physical proximity to others. these restrictions 69 are intended to benefit the physical health and safety of all people and must be adopted to save 70 lives. unfortunately, such directives come at a cost to the mental health and well-being a 71 substantial proportion of the population (rubin & wessely, 2020 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 16, 2020. . an updated systematic review on the effects of social distancing and quarantine on mental health 78 revealed that anxiety, depression, stress, anger, insomnia, hopelessness, and sadness were all 79 increased during those conditions (brooks et al., 2020) . a recent study (hu, su et al., 2020 ) from 80 a cross-national sample (n = 992) in china found that levels of anxiety increased, and 9.6% of 81 the population was anxious at clinically relevant levels. other behavioural problems also appear 82 during this period; participants in a nationwide survey recently published in china reported 83 nutritional issues, lack of ability to exercise and numerous changes in daily routines and habits 84 (qiu et al., 2020) . accordingly, psychosocial and behavioural dimensions seem associated under 85 quarantine conditions (filgueiras & stults-kolehmainen, 2020 unfortunately, resources are scarce in every field of the health system, including those for mental 107 health (qiu et al., 2020) . therefore, it is pivotal to establish a priori where and how to invest 108 those scarce resources. this is a difficult task because the current stressor is highly unique. 109 quarantine is due to a pandemic of truly global proportions that has reached every level of 110 society, with a long duration and remarkable social upheaval (who, 2020). there is no research 111 on the association between psychological, demographic and behaviour variables in the general 112 population during society-wide social isolation. furthermore, it is a consensus that psychological 113 phenomena, such as stress and depression, are multifactorial with a large amount of variables to 114 consider (who, 2004; 2016) . in order to help governments, service providers and scientists to 115 . cc-by 4.0 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 146 frequency" and "decreased exercise frequency") and (xiii) types of exercise (aerobic, anaerobic, 147 both, no exercise). it also collected data regarding diet and nutritional habits: (xiv) possible 148 changes on diet by comparing before and during quarantine; whether the person (xv) gained or 149 (xvi) lost more than 5 kilograms since the beginning of the quarantine. finally, attitudinal 150 questions were also computed. one question (xvii) asked about the amount of information the 151 participant felt he/she was receiving and the answers were provided in three possible categories 152 to choose from: "too much information", "enough information" and "little information". 153 . cc-by 4.0 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 16, 2020. . another three items were informed in a five-point likert-type scale ranging from 1 "totally 154 agree" to 5 "totally disagree"; the items were: (xviii) "do you feel imprisoned due to this 155 quarantine?", (xix) "do you feel you are able to understand what is happening?", (xx) "do you 156 trust your own ability to differentiate good from bad sources of information?". 157 the pss-10 (cohen & williamson, 1988 ) is a 10-item questionnaire that asks individuals about 158 their perception regarding stress-like symptoms. it is answered in a five-point likert-type scale 159 ranging from 0 "never" to 4 "very often" (scores range from 0-40). the population mean is 17.0 160 (sd = 5.02) with a score over 27 indicating excessive stress (cacciari, haddad, dalmas, 2016) . 161 the fdi (filgueiras et al., 2014 ) is a 20-item scale that asks individuals to grade the level of 162 association between the respondent's own self-perception and one-word items extracted from 163 depression symptoms listed in the dsm-v in the last fortnight. it is rated in a six-point likert-164 type scale ranging from 0 "not related to me at all" to 5 "totally related to me" (scores range 165 from 0-100 of the respondent who answers questions about own feelings in a four-point likert-type scale 170 ranging from 1 "not at all" to 4 "very much so" (scores range from 0-80). gender-specific 171 reference means are 36.5 (sd = 21.4) for men and 43.7 (12.6) for women, with cut-offs being 66 172 for men and 69 for women (pasquali, pinelli jr, soha, 1994) . 173 volunteers of the present research answered the questionnaires in the google forms online 174 platform that was configured in the same order of presentation: 1) term of consent, 2) 175 demographic and attitudinal questionnaire, 3) pss-10, 4) fdi, 5) s-stai, 6) thank you page. 176 those participants who answered "no" to the term of consent were addressed to the thank you 177 page without having any contact with the other questionnaires. first round of data collection 178 (time 1) took place between march 20 th and march 25 th , 2020, whereas the second round (time 2) 179 happened between april 15 th and april 20 th , 2020. 180 after data collection, google spreadsheets were utilized to consolidate the database and to 181 export it in the format .csv. then, researchers used spss (ibm, version 21.0) to run the analyses. 182 descriptive statistics of pss-10, fdi and s-stai were calculated for each categorical 183 (demographic) variable with exception of those that were answered in likert-type scales. due to 184 the large amount of variables collected in an online platform, cronbach's alpha (α) was 185 calculated for the three scales in time 1 and time 2; results were expected to show α > .70. 186 pairwise t-test comparisons between groups were computed to identify significant differences 187 between the first round (time 1) and second round (time 2) of data collection for the whole 188 sample. a repeated-measures anova was performed to compare within and between groups 189 for each demographic independent variable. furthermore, prevalence of stress, depression and 190 anxiety-like symptoms were calculated in percentage of participants above the means and cut-off 191 . cc-by 4.0 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 16, 2020. 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 16, 2020. for perceived stress, 237 (65.8%) and 269 (74.7%) of participants scored above the population 259 mean at time 1 and 2, respectively. prevalence of excessive stress (>2 sd above reference mean) 260 was 6.9% (ic 95 5.2%-8.6%) in the first round and 9.7% (ic 95 8.2%-11.2%) in the second 261 round. of the 34 individuals in this category, 94% of these individuals were women. 82% did no 262 exercise at all, but the remaining 18% complete 6 days a week of exercise. also, 0% utilized 263 tele-psychotherapy. regarding depression, 224 (62.2%) and 260 (72.2%) of participants were 264 above the reference mean at time 1 and 2, respectively. high depression (>2 sd above reference 265 mean) had a prevalence of 4.2% (ic 95 3.6%-4.8%) at time 1 and 8.0% (ic 95 7.1%-8.9%) at 266 . cc-by 4.0 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 16, 2020. . time 2. participants > 2 sd (n = 24) were mostly women (88%) and did not utilized tele 267 psychotherapy (88% as exercise frequency and perceived stress (r = -.28); whereas, moderate correlations were found 278 between the same variable between time 1 and time 2 (intertemporal correlations). tables 3 and 279 supplemental 2 provide the correlation matrix of the psychological variables. to understand what is happening, level of education and gender respectively. independent 291 variables explained 33% of the variance of depression in the second round of data collection. 292 finally, the state anxiety lmr depicted that the dependent variable (s-stai time 2) was 293 predicted, in order of association, risk for covid-19, feeling safe, the score of s-stai time 1, 294 weight loss, changes on diet, amount of information, feeling imprisoned and age. independent 295 variables of this lmr explained cumulatively 42% of the variance. table 3 presents the 296 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 302 midst of quarantine from the covid-19 pandemic, a novel, disruptive and society-wide stressor. 303 findings indicate that a substantial portion of respondents were distressed at both time points, 304 . cc-by 4.0 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 16, 2020. . https://doi.org/10.1101/2020.05.12.20099374 doi: medrxiv preprint with worsening mental health from the initiation of quarantine to a point one month later. more 305 specifically, increases in perceived stress, depression and state anxiety were observed, with a 306 gender x time interaction recorded for stress. men experienced increases in depression and 307 anxiety over time, but not for perceived stress. across genders, the number of days in quarantine 308 was linearly related to worse perceptions of perceived stress. repeated measures anova 309 revealed that 3 factors were all related to worse levels of stress, depression and anxiety: female 310 gender, worsening diet and excess of covid-19 information. in regression analyses, however, 311 mental health outcomes were influenced by a variety of other demographic, covid-19 specific, 312 and behavioural factors, such as use of tele-psychotherapy. exercise-related factors, such as 313 exercise frequency, were the predominate predictors of perceived stress. 314 a substantial portion of the participants reported levels of stress, depression and anxiety above 315 established means for the population. at time 2, greater than 70% of the sample was above the 316 normative mean for both stress and depression. for anxiety, >60% of both men and women were 317 above the normative mean. more importantly, some participants scored very high for mental 318 health disturbances, especially at time 2. for stress, 9.7% of the sample was above 2 sd at time 319 2, whereas the prevalence according to the brazilian norms is 6.8% (cacciari, haddad & 320 dalmas, 2016) . this was an increase from 6.9% at time 1. similar trends were seen for 321 depression (4.2% at time 1, 8.0% at time 2; versus a norm of 4.1%) (filgueiras et al., 2014 ) and 322 state anxiety (8.7% increasing to 14.9%; versus a norm of 9.4%) (pasquali, pinelli jr & 323 solha,1994) . this is similar to anxiety levels observed in a large sample during quarantine in 324 china (hu, su et al., 2020) . while the percentage of individuals scoring at these extremes is still 325 relatively low, it potentially represents a huge increase in burden to society when multiplied 326 across the entire population. mental health initiatives on the national level would have to be 327 scaled up to meet new demand (who, 2008) . key to this endeavour would be a) identifying 328 those most at risk and b) properly assessing their condition. 329 in the effort to identify those most at risk, pertinent predictors of mental health outcomes were 330 analysed. interestingly, each mental health indicator was predicted by a varying set of factors. condition of regrets about the past (buechler, 2015) , was understandably not predicted by 338 covid-19 related factors. only "understanding what is happening" was a significant inverse 339 predictor. stress was predicted by feelings of being imprisoned, days in quarantine and risk for 340 covid-19 and also by a number of exercise factors. 341 in general, exercise was associated with mental health outcomes in the expected manner -more 342 frequent exercise and aerobic exercise being related to the lowest levels of distress. for all 3 343 . cc-by 4.0 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 16, 2020. . mental health outcomes, those with no exercise (0 days per week) had the highest average levels 344 of stress (22.9 at time 1 to 26.4 at time 2), depression (69.0 to 74.6) and anxiety (48.2 to 54.7). 345 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 360 coaching reaching significance. an interaction was observed in that those who performed 361 aerobic exercise had the lowest levels of depression at both time points. in fact, those who did 362 aerobic exercise did not have any increase in depression. however, the clearest association of 363 exercise frequency and mental health was for anxiety. those at the highest levels of exercise had 364 the lowest anxiety and each day less was associated with more anxiety. 365 aside from exercise, there were notable findings for dietary habits and use of tele-366 psychotherapy. those who rated their dietary habits as becoming worse also had the highest 367 levels of stress, depression and anxiety. those with the highest levels of anxiety were those with 368 worsening diet at the second time point (effect size for interaction was .37). those who used 369 online nutrition services had lower levels of depression, but there was no difference for stress or 370 anxiety. those who utilized online psychotherapy reported lower levels of depression and 371 anxiety. while there is no income data to explain use of online resources, those using online 372 resources were more educated. thus one might surmise that those from better off demographic 373 groups are less affected partly because of greater access to resources. given the limited quantity 374 of resources to mitigate mental health impairments during crises, such as pandemic and 375 quarantine, it is crucial to identify the risk factors that may predispose individuals for worsening 376 outcomes. 377 despite the progress this study makes in tracking changes in mental health and identifying risk 378 factors, the current research does demonstrate some limitations. first of all, there was no pre-379 quarantine baseline and assessments spanned just a single month. furthermore, this was a 380 relatively well-off population with higher-educated individuals being over-represented in the 381 sample. there was no measure of adherence to quarantine guidelines. it is possible that those 382 with higher compliance to regulations could be of either higher or lower distress. to lessen 383 . cc-by 4.0 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 16, 2020. . survey fatigue for participants, validated measures of exercise and dietary habits, which can be 384 very lengthy, were not utilized. more importantly, the current data needs interpreted with some 385 caution because factors other than quarantine could contribute to changes in the mental health 386 outcomes observed, such as growing political and economic unrest in brazil (the lancet, 387 2020). also, it should be noted that effect sizes for changes over 1 month were small (cohen's d 388 were .25 -stress, .30 -depression, and .38 -anxiety), possibly because in some cases 389 individuals had improved mental health (n = 31; 8.6%) due to quarantine conditions, such as 390 being closer to loved ones throughout the day or being removed from dangerous work 391 environments. lastly, correlations between instruments at time 1 or time 2 were small -possibly 392 indicating the uniqueness of the quarantine as a stressor, particularly given the rapidly changing 393 circumstances during this time period (main, zhou et al., 2011) . 394 395 this study provides crucial data needed to understand how pandemic, state-mandated quarantine 397 is related to changes in mental health outcomes. from the time point when quarantine was 398 decreed until 1 month later, worsening perceived stress, depression and anxiety was observed in 399 this sample of the brazilian population. moreover, many individuals in the sample reported very 400 high levels of distress (> 2 sd). at the time of writing of this study, the quarantine is still being 401 enforced and cases of covid-19 and associated deaths on rising rapidly (the lancet, 2020; 402 imperial college covid-19 response team, 2020). future research should continue to track 403 these trends as the crisis unfolds. analyses from this study identified several risk factors for 404 mental health, including gender (being female), lower education, less exercise, worsening diet 405 and a lack of resources, such as access to tele-psychotherapy. covid-19 related factors 406 predicted anxiety and stress more so than depression. the implications of these data is clear; 407 mental health worsens with great change, requiring more resources to improve the experience of 408 life in quarantine. the extent to which these can be diligently developed and allocated will 409 depend on a data-driven process such as described here. 410 411 everyday stressors and gender differences in daily distress survey of stress reactions among health care workers 422 involved with the sars outbreak the psychological impact of quarantine and how to 424 reduce it: rapid review of the evidence la alegría, la vergüenza, el arrepentimiento y la tristeza en la terapia1 nível de estresse em trabalhadores readequados 428 e readaptados em universidade estadual pública. texto & contexto-enfermagem hope, hopelessness, and anxiety: a pilot 431 instrument 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recommendations the psychological effects of quarantining a city decreto 64.881: decreta quarentena no estado de são paulo, no contexto da 486 pandemia do covid-19 (novo coronavírus), e dá providências complementares stai: manual for the state-trait anxiety 490 inventory education level, income level and mental health 492 services use in canada: associations and policy implications the interplay between stress and physical activity in the 494 prevention and treatment of cardiovascular disease the effects of stress on physical activity and exercise. 496 sports medicine lower cumulative stress is associated with 498 better health for physically active adults in the community factors influencing psychological distress during a 500 disease epidemic: data from australia's first outbreak of equine influenza covid-19 in brazil the economic costs of mental disorders disease burden and government 506 spending on mental, neurological, and substance use disorders, and self-harm: cross-sectional, 507 ecological study of health system response in the americas physical activity and depression: is 150 min/week 510 of moderate to vigorous physical activity a necessary threshold for decreasing risk of depression 511 in adults? different views from the same data. social psychiatry and psychiatric epidemiology isolation, quarantine, social distancing and community 514 containment: pivotal role for old-style public health measures in the novel coronavirus (2019-515 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 521 report). geneva: world health organization considerations for quarantine of individuals in the context of containment for 524 coronavirus disease (covid-19): interim guidance the anxiolytic effects of exercise: a meta-analysis 528 of randomized trials and dose-response analysis the present research is funded by the coordenacao de aperfeicoamento de pessoal de nivel 413superior (capes) of the ministry of education of brazil under the proap program. key: cord-317441-tnde2jp5 authors: jewell, jennifer s; farewell, charlotte v; welton-mitchell, courtney; lee-winn, angela; walls, jessica; leiferman, jenn a title: mental health during the covid-19 pandemic in the united states: online survey date: 2020-10-23 journal: jmir form res doi: 10.2196/22043 sha: doc_id: 317441 cord_uid: tnde2jp5 background: the covid-19 pandemic has had numerous worldwide effects. in the united states, there have been 8.3 million cases and nearly 222,000 deaths as of october 21, 2020. 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 2020 using an online survey. the final convenience sample included 1083 us residents. the 71-item survey consisted of demographic questions, mental health and well-being measures, a coping mechanisms checklist, and questions about covid-19–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-19–specific concerns, and mental health and well-being outcomes. results: approximately 50% (536/1076) of the us sample was aged ≥45 years. most of the sample was white (1013/1054, 96%), non-hispanic (985/1058, 93%), and female (884/1073, 82%). participants reported high rates of depression (295/1034, 29%), anxiety (342/1007, 34%), and stress (773/1058, 73%). older individuals were less likely to report depressive symptomology (or 0.78, p<.001) and anxiety symptomology (or 0.72, p<.001); in addition, they had lower stress scores (–0.15 points, se 0.01, p<.001) and increased well-being scores (1.86 points, se 0.22, p<.001). individuals who were no longer working due to covid-19 were 2.25 times more likely to report symptoms of depression (p=.02), had a 0.51-point increase in stress (se 0.17, p=.02), and a 3.9-point decrease in well-being scores (se 1.49, p=.009) compared to individuals who were working remotely before and after covid-19. individuals who had partial or no insurance coverage were 2-3 times more likely to report depressive symptomology compared to individuals with full coverage (p=.02 and p=.01, respectively). individuals who were on medicare/medicaid and individuals with no coverage were 1.97 and 4.48 times more likely to report moderate or severe anxiety, respectively (p=.03 and p=.01, respectively). financial and food access concerns were significantly and positively related to depression, anxiety, and stress (all p<.05), and significantly negatively related to well-being (both p<.001). economy, illness, and death concerns were significantly positively related to overall stress scores (all p<.05). 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-19 pandemic has produced over 41 million confirmed cases and over 1.1 million confirmed deaths worldwide as of october 21, 2020 [1] . of these, nearly 8.3 million cases are in the united states, with nearly 222,000 deaths [1] . 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 [2] [3] [4] [5] . specific groups may be at increased risk for adverse mental health outcomes, such as frontline health care workers [6] 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 2014-2016 ebola crisis in west africa, among caretakers, survivors, their immediate contacts, and others [7, 8] . in addition, epidemics such as sars and hiv have been associated with depression and other mental health concerns among various groups [9] [10] [11] [12] [13] [14] . 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 [15] . financial struggles, including job loss and food insecurity, are known risk factors for mental illness, particularly anxiety, depression, and suicide [16, 17] . 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 [18] [19] [20] [21] [22] . 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-19 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 [23] . a review of the emerging literature regarding the effects of the pandemic suggests that symptoms of anxiety and depression are common [24] . in one study [25] , which used a representative sample and compared recent mental health concerns to those in 2018, 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 [25] . 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 1083 adults surveyed between april 7 and june 1, 2020, 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-19-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-19 pandemic received ethical approval from the colorado multiple institutional review board (comirb protocol #20-0676). survey data was collected between april 7 and june 1, 2020. 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 [26] . redcap (research electronic data capture) is a secure, web-based application designed to support data capture for research studies, providing the following features: (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) 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 $50 gift cards was offered. adults aged ≥18 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 1083 individuals. the 71-item survey consisted of demographic questions, mental health and well-being measures, coping mechanisms, and questions gauging covid-19-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=.93 in this sample). the swemwbs has a range of 7-35, with higher scores indicating higher well-being [27] . the patient health questionnaire-2 (phq-2) was used as a brief measure of depression (α=.81 in this sample). the phq-2 has a sensitivity of 83% and a specificity of 92% for major depression. the phq-2 has a range of 0-6 and was dichotomized for analyses using a cutoff score of ≥3 [28, 29] . generalized anxiety disorder (gad) was assessed using the gad-7, which has a sensitivity of 89% and a specificity of 82% (α=.92 in this sample). the gad-7 has a range of 0-21, and moderate or severe anxiety was based on a cut-off of ≥10 [30] . lastly, stress was assessed using a validated 1-item continuous measure with 5 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 [31] . the survey included a coping checklist, comprised of 12 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-19-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-19. 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 25; 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 10% missing data and data were missing completely at random (χ 2 9 =12.86, p=.17), 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-2 and gad-7 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 1 and 2) 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 5 unique sources of concern were entered into models (logistic regression models 3 and 4) to see which sources of concern predicted depression and anxiety outcomes after controlling for demographics. r 2 values, odds ratios, and p values for logistic regression models are presented. next, two hierarchical linear regression models were run (linear regression models 1 and 2) to explore associations between demographic variables and stress and well-being outcomes. in total, 5 unique sources of concern were entered into models (linear regression models 3 and 4) to see which sources of concern predicted stress and well-being outcomes after controlling for demographics. unstandardized coefficients, p values, and adjusted r 2 values are reported for all linear regression models. alpha (α) was set at .05. linear regression models for the well-being and stress outcomes are presented in table 3 . an increase in age decade was associated with a 0.15-point decrease in stress score (se 0.01, p<.001) and a 1.86-point increase in well-being score (se 0.22, p<.001). on average, individuals who did not have insurance reported a 0.72-point higher stress score (se 0.29, p=.002) and a 9.59-point lower well-being score (se 2.09, p<.001). no longer working due to covid-19 was associated with a 0.51-point increase in stress score and 3.90-point decrease in well-being score compared to individuals who were working remotely before and after covid ("no change" group; se 0.17, p=.02; se 1.49, p=.009). males also reported significantly lower stress scores compared to females (b=0.42, se 0.10, p<.001). financial concerns and food access concerns were significantly and positively related to depression, anxiety, and stress (all p<.05) and significantly negatively related to well-being (both p<.001). economy-, illness-, and death-related concerns were significantly and positively related to overall stress score after controlling for all demographic variables (all p<.05). 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 2 . logistic regression models showing associations between depression (models 1 and 3), anxiety (models 2 and 4), demographic variables, and sources of concern (n=1083). 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-19 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 2020. 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 [23] . 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-19 pandemic, rajkumar [24] found that older adults were at greater risk for mental health concerns [35] . 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-19 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 [16, 17] . employment, in contrast to unemployment, has been linked to decreased mental illness, including depression and anxiety, and increased mental well-being [36] . job instability, including moving from a permanent position to a temporary position, has been linked to increased mental illness [37] . 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 [38] . 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-19. 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-19, 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 [39] . this difference in stress levels may be due to gender differences in coping with stressful situations and differences in hormonal responses to stressful events [40] . 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 [41, 42] . each of the relationships between the concern items and mental health variables is consistent with expected outcomes from the covid-19 pandemic [43] . 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-19 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 45 of 50 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-19 makes it difficult to delineate accurate information from inaccurate information [44] . 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 [45] . online mental health assessments and self-directed mental health interventions have also been widely introduced in china, with their effectiveness remaining to be seen [46] . 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 population mental health can be used by public health practitioners, mental health practitioners, and policy makers in their decision making and in their framing of recommendations. covid-19 dashboard by the center for systems science and engineering (csse) multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science. the lancet psychiatry the emotional impact of coronavirus 2019-ncov (new coronavirus disease) mental health and the covid-19 pandemic the outbreak of covid-19 coronavirus and its impact on global mental health managing mental health challenges faced by healthcare workers during covid-19 pandemic a systematic review of mental health programs among populations affected by the ebola virus disease reflections on the ebola public health emergency of international concern, part 2: the unseen epidemic of 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depressive episode among adults prevalence of any anxiety disorder among adults. national institute of mental health psychometric properties of the warwick-edinburgh mental well-being scale (wemwbs) in northern ireland mental health services for older adults in china during the covid-19 outbreak. the lancet psychiatry the mental health benefits of employment: results of a systematic meta-review the impact of precarious employment on mental health: the case of italy the effect of medicaid on management of depression: evidence from the oregon health insurance experiment. milbank q stress#:~:text=women%20are%20more%20likely%20than%20men%20(28%20percent%20vs. ,10%20(39%20percent)%20men stress: physiology, biochemistry, and pathology financial concern predicts deteriorations in mental and physical health among university students food insecurity and mental health status: a global analysis of 149 countries mental health and the covid-19 pandemic distinguishing between factual and opinion statements in the news telemental health care, an effective alternative to conventional mental care: a systematic review online mental health services in china during the covid-19 outbreak. the lancet psychiatry this study was supported by nih/ncrr colorado ctsi grant number ul1 rr025780. 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-315247-86ibo5gn authors: ćosić, krešimir; popović, siniša; šarlija, marko; kesedžić, ivan; jovanovic, tanja title: artificial intelligence in prediction of mental health disorders induced by the covid-19 pandemic among health care workers date: 2020-06-17 journal: croat med j doi: 10.3325/cmj.2020.61.279 sha: doc_id: 315247 cord_uid: 86ibo5gn the coronavirus disease 2019 (covid-19) 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-19 pandemic. the article proposes a methodology for prediction of mental health disorders induced by the pandemic, which includes: phase 1) objective assessment of the intensity of hcws’ stressor exposure, based on information retrieved from hospital archives and clinical records; phase 2) subjective self-report assessment of stress during the covid-19 pandemic experienced by hcws and their relevant psychological traits; phase 3) design and development of appropriate multimodal stimulation paradigms to optimally elicit specific neuro-physiological reactions; phase 4) objective measurement and computation of relevant neuro-physiological predictor features based on hcws’ reactions; and phase 5) 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-19 pandemic and might assist mental health practitioners to make diagnoses more quickly and accurately. the coronavirus disease 2019 (covid-19) 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-19 pandemic. the article proposes a methodology for prediction of mental health disorders induced by the pandemic, which includes: phase 1) objective assessment of the intensity of hcws' stressor exposure, based on information retrieved from hospital archives and clinical records; phase 2) subjective self-report assessment of stress during the covid-19 pandemic experienced by hcws and their relevant psychological traits; phase 3) design and development of appropriate multimodal stimulation paradigms to optimally elicit specific neuro-physiological reactions; phase 4) objective measurement and computation of relevant neuro-physiological predictor features based on hcws' reactions; and phase 5) 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-19 pandemic and might assist mental health practitioners to make diagnoses more quickly and accurately. the coronavirus disease 2019 (covid-19) 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 (1). recent research related to the covid-19 pandemic (2,3) and 2015 middle east respiratory syndrome (mers) outbreak (4) 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 (5). 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 (6) and low self-control (7). 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 (8) 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-5) (9). in such circumstances, one of the greatest impacts of digital psychiatry, particularly applied artificial intelligence (ai) and machine learning (ml) (10-15) during the ongoing covid-19 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-5 (14) . 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 (13). 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 (16) , 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 (8,17), 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 (18, 19) due to heavy mental distress during the covid-19 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-19 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 (20) . 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 (17, 21) . 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-19 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 1 and in the following 5 phases, includes objective assessment of intensity of hcws' stressor exposure during the covid-19 pandemic described in phase 1, subjective assessment of stress experienced by hcws during the covid-19 pandemic based on the specific psychological questionnaire described in phase 2, distinctive stimulation paradigms designed and developed within phase 3, computed neuro-physiological features based on stimulation responses in phase 4, as well as statistical and ml data analysis described in phase 5. objective assessment of intensity of hcws' stressor exposure during the covid-19 pandemic is based on acquiring information from official hospital archives and clinical records regarding their daily schedules during the covid-19 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 (22-24), as well as stressors in virus outbreaks (25) (26) (27) (28) . 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 2: subjective stress assessment subjective assessment of stress experienced by hcws during their covid-19 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 29-38), as well as from specific covid-19 psychological questionnaires (25-28,39). self-reported subjective peritraumatic reactions represent a valuable complement to objective dimensions of stressful situations collected in phase 1 when trying to predict chronic mental health disorders, such as ptsd (40) . accordingly, subjective self-reports of individual covid-19 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 1. 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 2 ). 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 (21) 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 (41) , and prepulse inhi(49) , and are delivered binaurally through headphones. in order to induce laboratory fear, threat, or anxiety by means of predictable and unpredictable aversive events delivery (50), other aversive stimuli can be used, eg, combinations of airblasts to the neck, aversive images on the screen and sounds (51), as well as annoying but not painful electric shocks, eg, 1.5-2.5 ma, 5-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 (52,53). 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 (54, 55) . such measurements, obtained as a response to relevant stimuli described in phase 3, have the potential to objectivize traditional diagnostic methodology in psychiatry. in our laboratory, the biopac mp150 system (biopac systems inc., goleta, ca, usa) is used for the acquisition of the neuro-physiological signals. a gazepoint gp3 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 1100 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 (17, 21) . 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 (56,57) and heart rate variability (hrv) (58, 59) , respiratory sinus arrhythmia (21, 60) , hrv-based psychophysiological allostasis (21, 58) , emg-based and figure 2. design and development of multimodal stimulation paradigms for optimal elicitation of specific neuro-psycho-physiological individual reactions; adapted from (21) . 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 (61), various features related to speech prosody (62), prefrontal cortex activation on various cognitive tasks (43, 44) , and alpha band-related parietal eeg asymmetry (63) . 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 5 is accomplished using cloud storage and cloud computing resources, as shown in figure 1 . 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-19 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 (54) and telepsychiatry, which are efficiently applicable in the early stages of illness (64) . 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 4 can be obtained by the application of statistical analyses and ml techniques in relation to the objective stress intensity assessment from phase 1, as well as subjective self-report indicators of experienced stress and relevant psychological traits from phase 2. phase 5 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-19 pandemic, figure 3. 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; f0 voice -voice fundamental frequency; rms voice -voice energy -root mean square; f1-4 -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 (65) . 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 2 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 1 and phase 4, or phase 2 and phase 4. 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 4. 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-19-related research paper (28) uses data analogous to our proposed phase 1 and phase 2 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 1) and self-report data (phase 2) with the relevant neurophysiological features (phase 3 and phase 4). 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 (66) . 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 (11). 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 4 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 4 can be used to model various labels emerging from phases 1 and 2, such as estimation of objective stressor severity, available from phase 1; or classification of high vs low distress in hcws based on the data obtained in phase 2. 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-5. 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 (67) , which should also be regarded as highly important in the context of prediction of mental health disorders induced by the covid-19 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-19 disease (68) 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-19 pandemic. the main objective of the proposed methodology is to expand subjective metrics as predictors of potential mental health disorders mainly specific for phase 2 with more objective metrics derived in phases 1, 3, and 4. 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 (65,69,70) but has been subsequently extended to speech features (62) and various biomarkers (57, 71, 72) . these efforts should 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biological markers routinely collected from electronic medical records key: cord-261558-szll3znw 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-19: protocol for a randomized controlled trial date: 2020-11-06 journal: nan doi: 10.1101/2020.11.03.20225102 sha: doc_id: 261558 cord_uid: szll3znw 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-19 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-19 patients will be randomized to receive the psycovidapp intervention (intervention group) or a control app intervention (control group). a total of 440 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-21 questionnaire primary endpoint), insomnia (isi), burnout (mbi-hss), post-traumatic stress disorder (dts), and self-efficacy (gse). the study was funded in may 2020, and was ethically approved in june 2020. 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-19 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) [1] [2] [3] , 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 4 . this extreme situation has important implications for hcw´s mental health 5 . a recent systematic review examining the mental health problems among frontline hcws during viral epidemic outbreaks 5 observed a high prevalence of acute stress (40%), anxiety (30%), burnout (28%), depression (24%) and post-traumatic stress disorder (13%). 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 6 7 , france 8 , italy 9 , sierra leone 10 ). however, there is still very limited empirical evidence about the effectiveness of available interventions to protect mental health of hcws during viral pandemics 5 . 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 11 , schizophrenia 12 , substance use disorders 13 , and psychosis 14 , among others 15 . 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 15 16 . 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 17 . first, they can address non-treatment-seeking behaviour (a common issue among hcws 18 ), 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-2. however, their effectiveness in this specific context and population is largely unknown: as observed by a recent review 19 , only 27% of the studies about mental health apps to assist hcw during covid-19 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 98% of users 20 . on may 8 of 2020, spain reported the highest cumulative number of covid-19 infections among hcws around the world (30,663 infections -counting for 20% of all hcw infections worldwide) 21 . the pandemic produced very severe consequence in spanish hcws' mental health, with around 57% of hcws presenting symptoms of posttraumatic stress disorder, 59% of anxiety disorder, 46% depressive disorder, and 41.1% feeling emotionally drained 22 . 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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-19 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 23 . . cc-by-nc-nd 4.0 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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-19 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 1:1 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>18, who report having provided healthcare to patients with covid-19 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-19. this will include healthcare to any health problem patients may experience (i.e., not only caused by covid-19). 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 10 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 15 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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 1 . 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 1-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 24 . 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 48 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 14 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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 2020 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-19 pandemic (unpublished results). the intervention developers adhered to current recommendations for the development of mental health apps 25 . the psycovidapp intervention aims to prevent and mitigate the most frequent mental problems suffered by hcws attending the current covid-19 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 1): 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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 2 ). additional information is offered through links to web pages, articles, guides, videos and audios. all these contents will be permanently available during the 2-week intervention period. additionally, the intervention includes 14 temporal modules, which are available only for 24 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 3 ). box 1. description of the content of the psycovidapp intervention  section 1. 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 2. 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 3. 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 4. 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 5. 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 doi: medrxiv preprint participants in the control group will have access through the clinicovery© app to a control app intervention (see figure 4) . 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-19 pandemic. the information is organized in three sections: challenges faced by hcws during the covid-19 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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 (dass21) instrument 26 . the score ranges from 0 (worst outcome) to 21 (best outcome). the instrument contains three 7items scales, assessing presence and intensity of depression, anxiety and stress. items are based on a likert-scale ranging from 0 -3 points. secondary outcome measures will be the difference between intervention and control groups in the mean scores of the following instruments: 27 . the dts is a 17-item, likert-scale, self-report instrument that assesses the 17 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 0 to 68), severity score (ranging from 0 to 68), and total score (ranging from 0 to 136). higher scores are indicative of a worse outcome. the scope of the questionnaire to capture only post-traumatic stress disorders related with the covid-19 health emergency.  maslach burnout inventory -human services survey (mbi-hss) 28 . the mbi-hss is a 22item, likert-scale, self-reported instrument that assesses three domains of burnout: emotional exhaustion (9 items), depersonalization (5 items) and personal achievement (8 items). all mbi items are scored using a 7-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) 29 . the isi is a 7-item, likert-scale, self-reported instrument assessing the severity of both night-time and daytime components of insomnia. scores range from 0 (best outcome) to 28 (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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 doi: medrxiv preprint  general self-efficacy scale (gse) 30 . the gse is a 10-item, likert-scale, self-reported instrument that assesses optimistic self-beliefs to cope with a variety of difficult demands in life. scores range from 10 (worst outcome) to 40 (best outcome).  system usability scale (sus) 31 . the sus is a 10-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 0 (worst outcome) to 100 (best outcome). it is estimated that 440 participants (220 per group, allowing for 10% attrition) will be required to detect at least an effect size of 0.25 (cohen´s d) on dass21 with 80% power and alfa of 5% (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 2010 statements 32 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 95% confidence intervals. we will use multiple imputation by chained equations (mice) to fill in missing values (50 imputation sets) 33 . 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-21 median score). research ethical committee approval was obtained by the research ethics committee of the balearic islands (cei-ib ref no: ib 4216/20 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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 32 . 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-19 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-19 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 34 , 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 98% of users 20 .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 4.0 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 6, 2020. ; https://doi.org/10.1101/2020.11.03.20225102 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-19 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-19 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-19 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-2 (covid-19) mental health consequences of covid-19: the next global pandemic psychological status of medical workforce during the covid-19 pandemic: a cross-sectional study managing mental health challenges faced by healthcare workers during covid-19 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-19 on health care workers battle buddies: rapid deployment of a psychological resilience intervention for health care workers during the covid-19 pandemic psychological support system for hospital workers during the covid-19 outbreak: rapid design and implementation of the covid-psy hotline promoting resilience in the acute phase of the covid-19 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 sierra leone. international review of psychiatry a systematic assessment of smartphone tools for suicide prevention smartphone apps for schizophrenia: a systematic review technological interventions for medication adherence in adult mental health and substance use disorders: a systematic review improving adherence to web-based and mobile technologies for people with psychosis: systematic review of new potential predictors of adherence smartphone apps for the treatment of mental disorders: systematic review standalone smartphone apps for mental healtha systematic review and meta-analysis the use of digital applications and covid-19 doctors' health-seeking behaviour: a questionnaire survey a systematic literature review on e-mental health solutions to assist health care workers during covid-19 memo: an mhealth intervention to prevent the onset of depression in adolescents: a double-blind, randomised, placebo-controlled trial infection and mortality of healthcare workers worldwide from covid-19: a scoping review symptoms of posttraumatic stress, anxiety, depression, levels of resilience and burnout in spanish health personnel during the covid-19 pandemic spirit 2013 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-12 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-348436-mwitcseq authors: bu, f.; steptoe, a.; mak, h. w.; fancourt, d. title: time-use and mental health during the covid-19 pandemic: a panel analysis of 55,204 adults followed across 11 weeks of lockdown in the uk date: 2020-08-21 journal: nan doi: 10.1101/2020.08.18.20177345 sha: doc_id: 348436 cord_uid: mwitcseq there is currently major concern about the impact of the global covid 19 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 19 pandemic. data were from the ucl covid 19 social study; a panel study collecting data weekly during the covid 19 pandemic. the analytical sample consisted of 55,204 adults living in the uk who were followed up for the strict 11 week lockdown period from 21st march to 31st may 2020. 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 19 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, h1n1 influenza, ebola, and covid-19 1 2 3 4-6 . these effects include increases in stress, anxiety, insomnia, irritability, confusion, fear and guilty [4] [5] [6] . 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 2008-2010 recession, adults in the us who lost their jobs reallocated 30% 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 70% of the time on leisure activities, including socializing, watching television, reading, sleeping, and going out 7 . similarly, during the covid-19 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 8 . 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 9 . 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 10 , engaging in physical activity can reduce levels of depression and anxiety and enhance quality of life [11] [12] [13] [14] , 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 [15] [16] [17] [18] [19] . 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 20 , and sedentary screen time can increase the risk of depression 21 , 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 22 , lower motivation to engage in leisure activities 23 and increased engagement in screen time 24 . however, there have been little data on the association between daily activities and mental health amongst people staying at home during the covid-19 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 50,000 adults captured during the first two months of 'lockdown' due to the covid-19 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-19 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 25,26 . 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 27 . 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-19 social study; a large panel study of the psychological and social experiences of over 50,000 adults (aged 18+) in the uk during the covid-19 pandemic. the study commenced on 21st march 2020 involving online weekly data collection from participants for the duration of the covid-19 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 (12467/005) 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 21st march and 31st may 2020, when the uk went into strict lockdown on the 23 rd march and remained largely in that situation until 1 st june (although the lockdown measures started to be eased earlier in different uk nations). this provided us with data from 55,204 participants (total observations 338,083, mean observations per person 6.1 range 2 to 11). depression during the past week was measured using the patient health questionnaire (phq-9); a standard instrument for diagnosing depression in primary care 28 . 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-7); a well-validated tool used to screen and diagnose generalised anxiety disorder in clinical practice and research 29 . there are 7 items with 4-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 0 to 10: "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 4.0 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 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-19 (e.g. watching, listening, or reading news, or tweeting, blogging or posting about covid-19), (xi) watching tv, films, netflix etc. (not for information on covid-19), (xii) listening to the radio or music, and (xiii) browsing the internet, tweeting, blogging or posting content (not for information on covid-19). each measure was coded as, rarely (<30mins), low (30mins-2hrs) and high (>2hrs), except for low-intensity activities such as volunteering, gardening, exercising, reading, and arts/crafts. these were coded as, none, low (<30mins) and high (>30mins). 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 30 . 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 31 , which uses lags of the outcome variable (and regressors) as instruments in a first-difference model (eq. 1). the ab model uses −2 and further lags as instruments for −1 − −2 . the rationale is that the lagged outcomes are unrelated to the error term in first differences, − −1 , under a testable assumption that are serially uncorrelated. further, we treated the regressors, , as endogenous ( ( ) ≠ 0 ≤ , ( ) = 0, > ). therefore, should be instrumented by −2 , −3 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 32 . 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 33 . all analyses were carried out using stata v15 and the ab models were fitted using the user-written command, xtabond2 34 . . cc-by 4.0 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 doi: medrxiv preprint demographic characteristics of participants are shown in table s1 in the supplement. as shown in table 1 , the within variation accounted for about 15% of the overall variation for depression, and 16% for anxiety. anxiety explained 56% of the variance in depression (r=0.75, p<.001) and 27% of the variance in life satisfaction (r=-0.52, p<.001), while depression explained 32% of the variance in life satisfaction (r=-0.57, p<.001). there were also substantial changes in the time-use/activity variables ( figure 1 ). over 60% of participants changed status in all activities, except for volunteering (23%) and childcare (21%). 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 2 , model i-i). the largest decrease in depression was seen for participants who increased their exercise levels to more than 30 minutes per day, who increased their time gardening to more than 30 minutes per day, or who increased their work to more than 2 hours per day. on the contrary, increasing time spent following covid-19 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 3 , 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-19 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-19 news and communicating remotely with family/friends were associated with increases in anxiety ( table 2 , model ii-i). the largest decrease in anxiety was seen for participants who increased their time on gardening, exercising or reading to 30 minutes or more per day. when looking at the direction of the relationship (table 3 , model ii-ii), increases in gardening predicted a subsequent decrease in symptoms of anxiety. but increasing time spent following news on covid-19 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 4.0 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 doi: medrxiv preprint time spent following covid-19 news was associated with a decrease in life satisfaction ( table 2 , model iii-i). when looking at the direction of the relationship (table 3 , model iii-ii), increases in volunteering, gardening and exercising predicted a subsequent increase in life satisfaction. but increasing time spent following news on covid-19, 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-19 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-19 (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-19 predicted declines in mental health and wellbeing. our findings of negative associations between following the news on covid-19 and mental health echo a cross-sectional study from china showing that social media exposure during the pandemic is associated with depression and anxiety 1 . the fact that exposure to covid-19 news is largely screen-based, and the fact that watching high levels of television or high social media engagement unrelated to covid-19 was also found to be associated with depression could suggest that this finding is more about the screens than the news specifically 35 . however, the association with following the news on covid-19 was independent of these other screen behaviors and was found for even relatively low levels of exposure (30mins-2 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 36 , and information overload, whereby the amount of information exceeds people's ability to process 37 . 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 [10] [11] [12] [13] . exercise (including gentle activities such as gardening) can . cc-by 4.0 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 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) 38 . 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 39 . 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 16 . 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 17 19 . 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-19 pandemic 8 . 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 40 . this study has a number of strengths including its large sample size, repeated weekly follow-up over the 11 weeks of uk lockdown, and robust statistical approaches being applied. however, the ucl covid-19 social study did not use a random sample. . cc-by 4.0 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 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-19, 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-19 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-19 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 4.0 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 21, 2020. . cc-by 4.0 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 21, 2020. . cc-by 4.0 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 21, 2020. 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 doi: medrxiv preprint . cc-by 4.0 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 21, 2020. . https://doi.org/10.1101/2020.08.18.20177345 doi: medrxiv preprint . cc-by 4.0 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 21, 2020. the impact of covid-19 epidemic declaration on psychological consequences: a study on active weibo users the depressive state of denmark during the covid-19 pandemic anxiety and depression among general population in china at the peak of the covid-19 epidemic the experience of quarantine for individuals affected by sars in toronto survey of stress reactions among health care workers involved with the sars outbreak the psychological impact of quarantine and how to reduce it: rapid review of the evidence time use during the great recession lockdown in the uk: why women and especially single mothers are disadvantaged assessing the impact of the coronavirus lockdown on unhappiness, loneliness, and boredom using google trends fixed-effects analyses of time-varying associations between hobbies and depression in a longitudinal cohort study: support for social prescribing? gardening is beneficial for health: a meta-analysis physical activity for cognitive and mental health in youth: a systematic review of mechanisms growing minds: evaluating the effect of gardening on quality of life and physical activity level of older adults self-esteem, self-efficacy, and social connectedness as mediators of the relationship between volunteering and well-being who health evidence synthesis report. cultural contexts of health: the role of the arts in improving health and wellbeing in the who european region volunteering and well-being: do self-esteem, optimism, and perceived control mediate the relationship? why fiction may be twice as true as fact: fiction as cognitive and emotional simulation key: cord-343073-lwbddab2 authors: antiporta, d. a.; bruni, a. title: emerging mental health challenges, strategies and opportunities in the context of the covid-19 pandemic: perspectives from south american decision-makers. date: 2020-07-18 journal: nan doi: 10.1101/2020.07.16.20155630 sha: doc_id: 343073 cord_uid: lwbddab2 background mental health awareness has increased during the covid-19 pandemic. although international guidelines address the mental health and psychosocial support (mhpss) response to emergencies, regional recommendations on covid-19 are still insufficient. we identified emerging mental health problems, strategies to address them, and opportunities to reform mental health systems during the covid-19 pandemic in south america. methods an anonymous online questionnaire was sent to mental health decision-makers of ministries of health in 10 south american countries in mid-april 2020. the semi-structured questionnaire had 12 questions clustered into 3 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. shortand 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-19 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-19. funding none. the covid-19 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-19 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-19 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-19. 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-19 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 (1) , such as the covid-19 pandemic (2) , but awareness of mental health has already increased in media and academic platforms (3) . general population have reported anxiety and stress (4, 5) while health professionals and frontline aid workers reported fear and bereavement (6) . 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-19 pandemic (7). 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 (8) . 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 2015 that produced a shift from a hospital-centered mental health towards a community-based model (9) . in 2019 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 (10) . the sars-cov-2 virus has spread widely in south america with 1,119,575 confirmed cases and 48,860 deaths as of june 7 th , 2020(11). recent forecasting models suggest a dramatic scenario for the coming . cc-by-nc-nd 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07. 16.20155630 doi: medrxiv preprint months projecting substantial increase in cases and deaths by august(12), 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-19 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 10 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 10-15, 2020. eligible participants were 1) at least 18 years old, and, 2) 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-19 pandemic. the questionnaire (see table 1 ) had 9 country-specific questions, divided in three sections: 1) emerging challenges in mental health, 2) current and potential strategies . cc-by-nc-nd 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07.16.20155630 doi: medrxiv preprint (short-term, next two months, and medium-term, next six months, to face the pandemic, and, 3) strategies and opportunities for mental health reform. the questionnaire had a semi-structured format and was designed to last around 20 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 2 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 8 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(13). 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 4.0 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 18, 2020. . 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 9 out of 10 complete questionnaires representing 9 countries, and 44% of respondents were female. the median time for completion was 55 minutes (iqr=170 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 12 different emerging problems across countries. the most frequent mental health and psychosocial reactions reported were anxiety (12 mentions), stress (8 mentions), and fear (4 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 3 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 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07.16.20155630 doi: medrxiv preprint participants indicated several challenges for mental health care delivery arising during the covid-19 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 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07. 16.20155630 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-19. 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-19. 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 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07.16.20155630 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 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07. 16.20155630 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-19 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-19, 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-19. 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 4.0 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 18, 2020. . https://doi.org/10.1101/2020.07. 16.20155630 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 (8/9 respondents) and unicef (3/9 respondents). on average, each participant reported at least 3 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 4.0 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 18, 2020. . 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 (1, 14) . participants reported a higher burden of anxiety and stress in their respective countries. other reactions can be also expected in severe covid-19 infections such as fatigue, delirium, and neuropsychiatric syndromes (15) . detrimental effects in mental health have been reported in the general population (4, 5) , health providers (16) (17) (18) as well as overburdening health services (19) . 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 (20, 21) and violence(2), including violence against women and children. home confinement has increased the prevalence of depressive symptoms among children (22) . people with mental health disorders and disabilities may suffer further disruption in services and accommodation prior to covid-19 (23) . 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 4.0 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 18, 2020. where they implemented surveys, mental health education and psychological counselling services though online services (24) . in colombia, a smartphone application was launched to provide support to covid-19 affected populations; this application includes a component entirely dedicated to mental health that orient users and provides them with appropriate information(25). 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-19 pandemic, despite its inherent disruptive dramatic consequences, may generate important opportunities for improving mental health services(26). 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-19 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 4.0 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 18, 2020. . 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-19 pandemic in the subregion(11), 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 9 out of 10 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-19 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-19. 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-19 and physical distancing: the need for prevention and early intervention the lancet p. mental health and covid-19: change the conversation stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain covid-19 and mental health: a review of the existing literature 2019-ncov epidemic: address mental health care to empower society addressing mental health needs: an integral part of covid-19 response interim briefing note addressing mental health and psychosocial aspects of covid-19 outbreak peruvian mental health reform: a framework for scaling-up mental health services world health organization. the who special initiative for mental health (2019-2023): universal health coverage for mental health. geneva: world health organization, 2020. 11. pan american health organization (paho). cumulative covid-19 cases boadle a. who says the americas are new covid-19 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-19 pandemic mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (covid-19) pandemic in italy prioritizing physician mental health as covid-19 marches on mental health care for medical staff in china during the covid-19 outbreak mental health in the coronavirus disease 2019 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-19 epidemic online mental health services in china during the covid-19 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 2.1.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-277717-q6jbu0r3 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-19 pandemic on spanish healthcare workers: a large cross-sectional survey date: 2020-10-30 journal: nan doi: 10.1101/2020.10.27.20220731 sha: doc_id: 277717 cord_uid: q6jbu0r3 introduction: healthcare workers are vulnerable to adverse mental health impacts of covid-19. 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 18 healthcare institutions (6 aacc) in spain were invited to a series of online surveys assessing a wide range of individual characteristics, covid-19 infection status and exposure, and mental health status. here we report: current mental disorders (major depressive disorder-mdd[phq-8 [≥] 10], generalized anxiety disorder-gad[gad-7 [≥] 10], panic attacks, posttraumatic stress disorder -ptsd[pcl-5 [≥] 7]; and substance use disorder -sud-[cage-aid[≥]2]. severe disability assessed by the sheehan disability scale was used to identify "disabling" current mental disorders. results: 9,138 healthcare workers participated. prevalence of screen-positive disorder: 28.1% mdd; 22.5% gad, 24.0% panic; 22.2% ptsd; and 6.2% sud. overall 45.7% presented any current and 14.5% 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=5.74; 95%ci 2.53-13.03; mood: or=3.23; 95%ci:2.27-4.60; anxiety: or=3.03; 95%ci:2.53-3.62); age category 18-29 years (or=1.36; 95%ci:1.02-1.82), caring "all of the time" for covid-19 patients (or=5.19; 95%ci: 3.61-7.46), female gender (or=1.58; 95%ci: 1.27-1.96) and having being in quarantine or isolated (or= 1.60; 95ci:1.31-1.95). conclusions: current mental disorders were very frequent among spanish healthcare workers during the first wave of covid-19. 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-19 very often. covid-19 represents a major health challenge worldwide and several populations may experience adverse mental health related to the covid-19 pandemic 1,2 . 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 12 times more risk for a positive covid-19 test 3 . although with noticeable regional and international variations, it is estimated that 10-20% of all covid-19 diagnoses occur in this population segment 4, 5 . 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-19 was associated with an increase of symptoms of depression, anxiety, insomnia, and burnout, as well as other adverse psychosocial outcomes. luo et al 6 , estimated that a quarter of healthcare workers suffered from anxiety (26%), depression (25%), and that about a third suffered substantial stress. similar figures were reported in other systematic reviews [7] [8] [9] . in spain, a number of studies have been carried out to assess mental health of healthcare workers during the first wave of the covid-19 pandemic [10] [11] [12] [13] [14] . 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-19 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-19 pandemic using a representative sample and well-validated screeners of common mental disorders. specifically, our objectives were to estimate 1) 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 2) associations of individual and professional characteristics, covid-19 infection status, and covid-19 exposure with these mental disorders. 6 a multicenter, prospective, observational cohort study of spanish healthcare workers was carried out in a convenience sample of 18 health care institutions from 6 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-19 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-19 outbreak in spain (may 5 -september 7, 2020). 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 21.4 minutes (iqr 16.5-30.0). informed consent was obtained from all participants at the first survey page. up to two reminder emails were sent within a 2-4 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 30-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-8). we used the spanish version of the phq-8 (https://www.phqscreeners.com) with the cut-off point of 10 or higher of the sum score to indicate current mdd. the phq-8 shows high reliability (>0.8) and good diagnostic accuracy for major depressive disorder (auc>0.90) 15 . -generalized anxiety disorder (gad): evaluated with the seven-item generalized anxiety disorder scale (gad-7), which has a good performance to detect anxiety (auc>0.8 16 ). we used the spanish version of the gad-7 (https://www.phqscreeners.com) and considered the cut-off point of 10 or higher to indicate a current gad. -panic attacks: the number of panic attacks in the 30 days prior to the interview was assessed with an item from the world mental health-international college student-wmh-ics 17 . a dichotomous variable was created to indicate the presence of panic attacks. -posttraumatic stress disorder (ptsd): assessed using the 4-item version of the ptsd checklist for dsm-5 (pcl-5) [18] [19] which generates diagnoses that closely parallel those of the full pcl 5 (auc>0.9), making it well suited for screening 19 . we used the spanish version of the questionnaire 20 , and considered a cut-off point of 7 to indicate current ptsd. -substance use disorder (sud): evaluated with the cage-aid questionnaire, that consists of 4 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 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220731 doi: medrxiv preprint cage-aid has been proved useful in helping to make a diagnosis of alcoholism 21 and substance use disorder 22 . the questionnaire has been adapted into spanish. a cut-off point of 2 was considered to indicate current sud 23 . -disabling mental disorder: a mental disorder was considered "disabling" if the participant reported severe role impairment during the past 12 months according to an adapted version of the sheehan disability scale 24, 25 . a 0-10 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 (0), mild (1-3), moderate (4-6), severe (7) (8) (9) , and very severe (10) interference. severe role impairment was defined as having a 7-10 rating [26] [27] [28] . -prior lifetime mental disorders: lifetime mental disorders prior to the onset of the covid-19 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 28 . we assessed the frequency of direct exposure to covid-19 infected patients during professional activity using one 5-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-19 patients. we assessed covid-19 infection status asking whether the respondent had been hospitalized for covid-19 infection and/or had a positive covid-19 test or medical diagnosis not requiring hospitalization. we also asked whether the respondent had been in isolation or quarantine because of exposure to covid-19 infected person(s), and whether s/he had close ones infected with covid-19. we assessed: age; gender; country of birth; marital status; having children in care; living situation; and profession into 5 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 (2020/9203/i) and by the corresponding irbs of all the participating centers. the study is registered at clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/nct04556565). analyses were restricted to the n = 9,146 respondents who completed all mental health items of the questionnaire. of them, an additional n = 8 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 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220731 doi: medrxiv preprint median proportion of missingness per variable was less than 1%. however, to optimize survey timings, the sheehan disability scale was assessed only in a random 60% 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 40 imputed datasets and 10 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-19 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 29 with a false discovery rate of 5%. 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 95% 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-19 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 30, 31 . analyses were performed using r v3.4.2 32 and sas v9.4 33 . 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 30, 2020. ; https://doi.org/10.1101/2020.10.27.20220731 doi: medrxiv preprint a total of 9,138 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 (26.4%). 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 89.0%, and the survey completion rate (i.e., those that completed the survey among those that agreed to participate) was 80.8%. 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 12.5% (see supplementary table 1 ). the first two columns of table 1 show the size and weighted distribution of the sample studied. healthcare professionals were mostly female (77.3%), the larger age group was 30-49 years (45.8%), just over half were married (53.0%), four out of ten were living with children (41.4%), and 57.2% were living in an apartment. about a fourth (26.4%) were physicians, and 30.6% were nurses, and the majority were working in a hospital (54.1%). almost 80% of participants were directly involved in patient care, although less than a half (43.6%) were directly exposed to covid-19 patients all or most of the time (i. e., frontline workers). almost a fifth (17.4%) had covid-19, 13.8% had their spouse/couple, children or parents infected with covid-19, and up to 25 .5% had been isolated or quarantined. an important proportion (41.6%) reported a lifetime mental disorders before the pandemic. table 1 , the prevalence of current mental disorders is presented according to the above variables. overall, 28.1% met criteria for major depressive disorder, between 22.2% and 24.0% met criteria for anxiety disorders (gad, panic attacks, or ptsd), and 6.2% met criteria for substance use disorder. in all, almost half of the sample (45.7%) met criteria for current mental disorder and about one in seven (14.5%) 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 12 years of age or not having children at home. auxiliary nurses and nurses showed the highest prevalence of current mental disorders (59.5% and 50.4%, respectively). there was a clear positive trend with higher exposure to covid-19 patients, and those having the disease --in particular those 112 professionals who had been hospitalized for covid-19, having been isolated or quarantined, and whose parents, children or partner were infected with covid-19. 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 1 , 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 30, 2020. ; current mental disorders according to prior lifetime mental disorders: figure 1 shows current prevalence of mental disorders according to pre-covid-19 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 1 , about here] figure 2 shows current prevalence of any mental disorders (both disabling and non-disabling), according to pre-covid-19 pandemic prior lifetime mental disorders. among workers without prior mental disorders, the prevalence of any mental disorder (new onset) was almost 34% and one in four of those were disabling mental disorders (figure 2.a) . among healthcare workers with any prior lifetime disorder, the prevalence of current disorders (persistence/relapse) was much higher (61%), and more frequently disabling (i.e., one in three) (figure 2 .b). [ figure 2 , about here] factors associated with current mental disorders: table 2 shows bivariate associations of individual characteristics, personal covid-19 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=9,138) that had been presented in table 1 in the form of odds ratios, once adjusting by week of the survey and by healthcare center. table 2 also shows these associations, stratifying by prior lifetime mental disorders. columns 3-4 present data for those with no mental disorders prior to the covid-19 pandemic and columns 5-6 refer to those reporting mental disorders before the first wave of the covid-19 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-19 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 2 , about here] table 3 presents multivariable analyses of the associations described above, adjusting by all individual characteristics, covid-19 exposure factors, and healthcare center and week of interview. being female, and between ages 18-29 and being 30-49 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 1 1 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 3 , 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, 1 in 7 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-19 pandemic. such a combination is potentially more valid and useful for services planning purposes, than descriptive information on psychological symptoms 34, 35 . 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-19 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 (28.1%) and gad (22.5%) was well within the range of meta-analytic reports of healthcare workers studied in predominantly asian healthcare settings 6, [8] [9] . our estimated prevalence of ptsd (22.2%) was also remarkably similar to that reported among healthcare workers in a meta-analysis (20.7%) 5 . substance use disorder was present in 6.2% of our sample. only a few studies have reported empirical estimates of this disorder during the covid-19 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 36 and france 37 . 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-19 pandemic. the prevalence in our study (i.e., 45.7% of the responding healthcare workers meet criteria for any of the five assessed disorders) is somewhat higher than the 40.9% of ≥ 1 adverse mental or behavioral health symptom in the adult us population 36 . more importantly, 1 in 7 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 1.53 to 8.25). 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 1 3 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 27%. in addition, invitations were limited to a maximum of 2 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-19 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-19 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 15 , generalized anxiety disorder 16 and post-traumatic stress disorders 19 . 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 38 . 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 34, 35 . healthcare workers with disabling current mental disorder in our study had much more frequent (between 2 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-19 pandemic, with 1 in 7 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-19 patients, who had been infected or have been quarantined or isolated, as well as female workers, auxiliary nurses and nurses. 1 4 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 30, 2020. (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 30, 2020. ; table 1 (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 30, 2020. ; (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 30, 2020. ; multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science covid-19 pandemic and mental health consequences: systematic review of the current evidence risk of covid-19 among front-line health-care workers and the general community: a prospective cohort study characteristics of health care personnel with covid-19: united states covid-19 in italy: momentous decisions and many uncertainties the psychological and mental impact of coronavirus disease 2019 (covid-19) on medical staff and general public -a systematic review and metaanalysis impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis impact of sars-cov-2 (covid-19) on the mental health of healthcare professionals: a systematic review mental health impact of covid-19 pandemic on spanish healthcare workers psychological impact of covid-19 on a sample of spanish health professionals compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the covid-19 health crisis in spain job insecurity, economic hardship, and sleep problems in a national sample of salaried workers in spain the phq-9: validity of a brief depression severity measure preliminary reliability and validity of the generalized anxiety disorder questionnaire-iv: a revised self-report diagnostic measure of generalized anxiety disorder clinical reappraisal of the composite international diagnostic interview screening scales (cidi-sc) in the army study to assess risk and resilience in servicemembers (army starrs) the ptsd checklist for dsm-5 (pcl-5) developing an optimal short form of the ptsd checklist for dsm 5 (pcl 5) cognitive processing therapy for posttraumatic stress disorder (ptsd) screening instruments for detecting illicit drug use/abuse that could be useful in general hospital wards: a systematic review assessing psychiatric impairment in primary care with the sheehan disability scale disability and treatment of specific mental and physical disorders across the world the world mental health (wmh) survey initiative version of the world health organization (who) composite international diagnostic interview (cidi) prevalence of mental disorders and psychosocial impairments in adolescents and young adults the role impairment associated with mental disorder risk profiles in the who world mental health international college student initiative controlling the false discovery rate in behavior genetics research multivariate imputation by chained equations in r flexible imputation of missing data r: a language and environment for statistical computing population level of unmet need for mental healthcare in europe revised prevalence estimates of mental disorders in the united states: using a clinical significance criterion to reconcile 2 surveys' estimates mental health, substance use, and suicidal ideation during the covid-19 pandemic -united states marital status -married (vs single, divorced or legally separated note: or, odds ratio; 95%ci, 95% confidence interval (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. key: cord-332579-7950xjmv 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-19, sars-cov, mers, and influenza). date: 2020-06-07 journal: nan doi: 10.1101/2020.06.04.20122812 sha: doc_id: 332579 cord_uid: 7950xjmv background: mental health has become one of the fundamental priorities during the covid-19 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-19 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-19, sars-cov, mers, and influenza) in people 65 years or older. data source: original articles published until june 1st, 2020, 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-19 living systematic map and the publicly available publication list of the covid-19 living systematic review will be incorporated for preprints and recent covid-19 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-19 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". 1 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." 2 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-2 virus (covid-19) 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. 3 a good point of comparison to understand covid-19 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, 4 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. 5-8 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 9 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-19 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-19 pandemic has demonstrated to be a critical challenge for older people's physical health. people 65 years or older are the population with the highest risk of mortality associated with covid-19 worldwide. 10 patients with multimorbidity and cardiovascular risk, which increase exponentially after 65 years old, are particularly prone to manifest severe symptoms. [11] [12] [13] 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-19 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. 14, 15 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. [16] [17] [18] [19] [20] 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-19 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, 21, 22 and others have estimated that older adults are 2.11 and 1.73 more likely to experience ptsd and adjustment disorder symptoms after natural disasters compared to younger adults, respectively. 23 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. 24 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. 25, 26 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. 27 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-19, 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, 9 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-19 on the mental wellbeing of elderly population, 28 have focused their reviews just on clinical outcomes related to mental health. in this context, and considering the increasing number of covid-19 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 4.0 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 7, 2020. . 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 1) to describe the associations between respiratory propagated epidemic and pandemics and older adult's mental health, 2) 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, 3) to assess the effect of interventions in the older adult's mental health associated to respiratory propagated epidemic and pandemics, and 4) 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. 29 we will select studies that: 1) describe the effects of acute respiratory disease propagated-type epidemics or pandemics on mental health or psychosocial parameters, and 2) 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 60 years or older residing in any setting. research involving people from other age groups (e.g. children, adolescents, adults) additionally to people 60 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. 2014: 4 sars coronavirus (sars-cov), middle east respiratory syndrome (mers), and influenza/flu (h1n1, h5n1). sars coronavirus 19 (sars-cov-2 or covid-19) 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. 4 . cc-by-nd 4.0 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 7, 2020. . https://doi.org/10.1101/2020.06.04.20122812 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." 1 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 1st, 2020, 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-19 related articles will be identified in two other ways. first, studies in the eppi centre covid-19 living systematic map of the evidence screening review 30 which are tagged with "health impacts," "social/economic impact," or "mental health impacts" will be added to the screening workflow. the eppi centre covid-19 map consists of studies on covid-19, identified in medline and embase, and published in 2019 or later. second, for better coverage of preprints, we will use the publicly available publication list of the covid-19 living systematic review 31 , which retrieves articles from the preprints databases biorxiv and medrxiv and it is continuously updated. because more covid-19 related articles are published week by week, after the title-abstract screening is completed, another search exclusively for covid-19 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-19 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-19 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 4.0 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 7, 2020. . https://doi.org/10.1101/2020.06.04.20122812 doi: medrxiv preprint were incorporated from other systematic reviews about psychosocial health and wellbeing and based on expert opinion. 32, 33 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. 34, 35 studies will be divided into two main categories for its analysis: 1) studies describing the direct effect of virus infection on mental health outcomes, and 2) 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: 1) ttype of study design, 2) temporality of the evaluation of the exposure: concordance in the evaluation timing of the impact of the epidemic/pandemic episode with the study goals, 3) outcome evaluation: evaluation of the outcome with standardized and defined measurement instrument or methods, 4) adjusted analysis: the . cc-by-nd 4.0 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 7, 2020. . 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. 5) attrition bias: for cohort studies, 30% 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: 1) type of study design, 2) bias arising from the randomization process, 3) bias due to deviations from intended interventions, 4) bias due to missing outcome data, 5) bias in measurement of the outcome, and 6) 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. 36, 37 intervention study risk of bias follows the cochrane handbook for systematic reviews. 38 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 95% 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 95% cis will be considered. unadjusted and adjusted results will be extracted. these measures will be extracted for people 65 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 i2 statistics, classifying no heterogeneity (<25%), low (25-49%), moderate (50-74%), and high heterogeneity (equal or >75%). we will decide on the appropriateness of conducting a meta-analysis based on qualitative and quantitative information. . cc-by-nd 4.0 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 7, 2020. . 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 1 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 2 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 4.0 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 7, 2020. . situation. 3 this topic takes major relevance in the current scenario triggered by the covid-19 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 65 years or older have been increasingly exposed to situations that are a threat to their mental health such as isolation and loneliness. 39 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. 24 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-19 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 health: concepts, emerging evidence, practice (summary report). geneva: world health organization what is mental illness? washington: american psychiatric association multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care: who guidelines. geneva: world health organization, 2014. 5.-shimizu k. 2019-ncov, fake news, and racism mental health status of people isolated due to middle east respiratory syndrome stress and psychological distress among sars survivors 1 year after the outbreak long-term psychiatric morbidities among sars survivors psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid-19 pandemic older adults presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region out-of-hospital cardiac arrest during the covid-19 outbreak in italy active coping shields against negative aging self-stereotypes contributing to psychiatric conditions experiences of ageism and the mental health of older adults moderate to severe depressive symptoms and rehabilitation outcome in older adults with hip fracture factors mediating the effects of a depression intervention on functional disability in older african americans psychosocial and socioeconomic determinants of cardiovascular mortality in eastern europe: a multicentre prospective cohort study the relationship of psychosocial factors to total mortality among older japanese-american men: the honolulu heart program are older people more vulnerable to long-term impacts of disasters? individual, community, and national resiliencies and age: are older people less resilient than younger individuals? mental 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-19 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-19: 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-3): 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 6 available from www.training.cochrane.org/handbook social isolation and loneliness in older adults-a mental health/public health challenge key: cord-028178-77zq31tw authors: d’acci, luca s. title: urbanicity mental costs valuation: a review and urban-societal planning consideration date: 2020-06-30 journal: mind soc doi: 10.1007/s11299-020-00235-3 sha: doc_id: 28178 cord_uid: 77zq31tw 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 19 trillion dollars in global gdp between 2011 and 2030 and of around 7 trillion for the year 2030 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 € 1.2 trillion could be saved yearly worldwide. even a reduction of only 20% in urban mental illness rate would save around 250 billion dollars yearly. disorders are also the primary cause of disability-adjusted life years worldwide (bloom et al. 2012) . 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 89 studies: coid et al. 2020; evans et al. 2020; vargas et al. 2020; sampson et al. 2020; lecic-tosevski 2019; reed et al. 2018; evans et al. 2018; castillejos et al. 2018; kirkbride et al. 2006 kirkbride et al. , 2018 cooper et al. 2017; besteher et al. 2017; gruebner et al. 2017; krzywicka and byrka 2017; vassos et al. 2016; newbury et al. 2016; brockmeyer and d'angiulli 2016; adli et al. 2016; freeman et al. 2015 , wilker et al. 2015 peterson et al. 2015; haddad et al. 2015; vaessen et al. 2015; steinheuser et al. 2014; haluza et al. 2014; krabbendam et al. 2014; streit et al. 2014; calderón-garcidueñas et al. 2013; heinz et al. 2013; bedrosian and nelson 2013; stevens et al. 2013; tandon et al. 2012; lederbogen et al. 2011; fonken et al. 2011; larson et al. 2011; galea et al. 2011; mcclung 2007 mcclung , 2011 meyer-lindenberg 2010; park et al. 2010; bowler et al. 2010; kelly et al. 2010; mortensen et al. 2010; levesque et al. 2011; gwang-won et al. 2010; tae-hoon et al. 2010; peen et al. 2007 peen et al. , 2010 van os et al. 2010; kennedy et al. 2009; bentall et al. 2008; march et al. 2008; joens-matre et al. 2008; fuller et al. 2007; graziano and cooke 2006; maas et al. 2006; mortensen 2001a, b, 2006a, b; weich et al. 2006; krabbendam and van os 2005; tsunetsugu and miyazaki 2005; wang 2004; sundquist et al. 2004; van os 2004; van os et al. 2004; mcgrath et al. 2004; harrison et al. 2003; caspi et al. 2003; frumkin 2001; allardyce et al. 2001; haukka et al. 2001; torrey et al. 2001; van os et al. 2001; eaton et al. 2000; schelin et al. 2000; marcelis et al. 1999; mortensen et al. 1999; marcelis et al. 1998; thornicroft et al. 1993; lewis et al. 1992; cohen 1982; eaton 1974; christmas 1973; faris and dunham 1939; white 1903 . paykel et al. (2000 , 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. (2016) , the rate of incidence of nine types of psychiatric disorders is in average 1.6 times higher in the capital city than in the rural areas, with 'schizophrenia and related disorders' even almost double (1.83), while the review of mcgrath et al. (2004) of 68 studies found a schizophrenia incidence rate 2 times higher in urban areas than in mixed rural/urban areas; a rate that rises up to a 2.75 times greater risk of schizophrenia when one has lived 15 years of her early life in a capital city rather than a rural area (pedersen and mortensen 2001a) . peen et al. (2007) reported an odds-ratio for mental disorders in very highly urbanized areas of 1.6 related to non-urbanized (1.8 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. (1998 marcelis et al. ( , 1999 , mortensen et al. (1999) , schelin et al. (2000) , allardyce et al. (2001) , pedersen and mortensen (2001a, b) , van os et al. (2001 van os et al. ( , 2004 , harrison et al. (2003 ), sundquist et al. (2004 , pedersen and mortensen (2006a, b) , kirkbride et al. (2006) , haukka et al. (2001) and torrey et al. (2001) . an increase as high as fourfold was found in eaton et al. (2000) . a meta-analysis review summarised that urban dwellers have a 1.4 times greater risk of mood disorders than non-urban (peen et al. 2010) . 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. (2008 and lederbogen et al. (2011) . 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 2018, p. 95) . similarly, to european surveys, 44% of americans voted small towns/rural environments as the best kind of places to live and only roughly one in five (20%) voted cities (knox and pinch 2006) . another questionnaire (d'acci 2020) reported that only 32% of respondents prefers to live in a city rather than (ceteris paribus) in a natural environment (36%), in a town/village (24%), in a suburb (6%), while 2% of them were indifferent. in line with these stated residential preferences, happiness seems to decrease when urbanicity levels increase (sander 2011; lawless and lucas 2010) , 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. 2019; easterlin et al. 2011; gilbert et al. 2016; helliwell et al. 2018; fassio et al. 2013 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 2017; gustavsson et al. 2011) . early commencement mental disorders result to be statistically significantly associated with the interruption of secondary education (leach and butterworth 2012) , which in turn means less likelihood to be employed in higher skilled professions (schofield et al. 2011) . as expected, psychiatric disorders between the ages of 18 and 25, after controlling for confounding variables, was statistically significantly (p value < 0.05) negatively linked with workforce participation, income and economic living standards at age 30, and, more generally, cumulative episodes of psychiatric disorders negatively affect life outcomes (gibb et al. 2010 ). 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. 2007 ). 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. 2011 ). this psychological distress cost related to lower productivity has been estimated in 2010 to be a$ 5.9 billion (equivalent to roughly a$ 7.5 billion in 2019) per annum in australia (hilton et al. 2010) , and the individuals' loss due to depression has been assessed as a 73% lower income than their full-time counterparts, while those deciding to retire early because of their mental health issues have 78% lower incomes, which at a national aggregate level means us$ 407 million in transfer payments, $ 278 million in lost income taxation revenue, and almost $ 2 billion in gdb, just in 2009 (schofield et al. 2011) . reports for canada (smetanin et al. 2011 ) assessed that in 30 years (2011-2041) the cumulative costs related to mental illness could be around us$ 3 trillion (based on us$ 2019)-even if underestimated for the lack of some types of cost and of mental illness-and in 2010-2011 australia spent a$ 6.9 billion (7.7% of all government health outlay) in mental health services by governments and health insurers. 1 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. 2012; hilton et al. 2010; jacobs et al. 2010) . the 2018 oecd report estimates as more than 4% of gdp (around € 600 billion) the costs due to mental illness across europe (oecd 2018), while gustavsson et al. (2011) estimated it to be around € 800 billion for the 2010, including norway, iceland and switzerland to the 28 european countries. a team of members from the world economic forum and the harvard school of public health (bloom et al. 2012 ) used different methods (although non comparable among each other) to estimate mental disorders costs: (1) direct and indirect costs by human capital approach (the standard cost-of-illness method), (2) impact on economic growth (macroeconomic simulation), and (3) 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 (1), 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 (2), 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 (3) 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 (1) the team (bloom et al. 2012 ) estimated a world cost for mental illness of us$ 2.5 trillion for the year 2010 alone, and us$ 6 trillion for the year 2030 alone, two-thirds of which for indirect costs. by method (2) they estimated a world cumulative gdp loss of us$ 16.3 trillion (usa dollars 2010) due to mental health alone over 20 years (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) (2019) (2020) (2021) (2022) (2023) (2024) (2025) (2026) (2027) (2028) (2029) (2030) . by method (3) they estimated a world output loss of us$ 8.5 trillion in 2010, and us$ 16.1 trillion in 2030. converted into us$ for the year 2019, they resulted approximatively us$ 19.2 trillion of gdp loss during the 20 years between 2011 and 2030; us$ 7.1 trillion of human capital loss for the year 2030 alone; and us$ 18.9 trillion the willingness to pay for the year 2030 alone. all these estimates, even if already showing impressively high economic loss translations, are very likely underestimated (whiteford et al. 2016 ). 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 2 and even becoming law (since july 2015, 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 8 to 6 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 2020) 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$ 2.7 trillion 3 would be use for mental urban costs in 1 year alone (2030, when, according to un 2019, a 60.4% of urban population is expected). if we prefer to avoid forecasts so far away in time (2030) and refer our thoughts only to real data from the past, in 2010 the money actually spent for mental illness was us$ 2.9 trillion worldwide (2019 dollars). an amount also in line with the 4% of gdp costs for mental illness assessed by the 2018 oecd regarding europe: in fact if we use this gdp percentage at the world level, the world gdp in 2010 was around (in current dollars) us$ 66.037 trillion, 4 whose 4% means us$ 2.64 trillion, namely around us$ 2.9 trillion in 2019 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 2010 was around 51.6%, 5 therefore us$ 1 trillion 6 could have been saved in urban mental illness costs in that year alone. in 2018 the world urban population was around 55.3% and the world gdp around us$ 85.9 trillion 7 (current dollars), meaning roughly us$ 87.4 trillion today, whose 4% is around us$ 3.5 trillion which, following the same approximate reasoning (and assuming a similar percentage of gdp use) means that roughly us$ 1.24 trillion 8 could have been not spent in mental illness due to urbanicity issues. if we assume a reduction of "only" 20% of urban mental illness rate, we would still save around 250 billion dollars yearly. to put these trillions in context, the entire apollo space program (1961) (1962) (1963) (1964) (1965) (1966) (1967) (1968) (1969) (1970) (1971) (1972) (1973) , including the 1969 walks on the moon, still one of the major humanity achievements, costed only around us$ 175 billion 9 (in 2019 dollars); almost 6 times less than what can be saved in only 1 year in mental illness due to urban life. an equivalent program but on mars (sending nine crews), could cost around us$ 1.5 trillion, 10 while the mars 2020 rover mission costs 'only' between 2 and 3 us$ trillions. another colossal human achievement, the 13 year human genome project costed 'just' us$ 2.7 billion (1991 adjusted into 2018 dollars 11 ). 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 transforming the physical structures, forms and functioning of our current urban environments it would have an enormous potential economic impact environmentally, infrastructurally, but also psychologically speaking. from the academic literature we can say that the urban impact on mental health implies an approximately twofold increase in the rate of mental issues compared to the rural environment. reports estimated a us$ 2.9 trillion global expense for mental disorders in 2010 alone and forecasted to become as high as us$ 7.1 trillion in the year 2030 alone. if we make a rather imaginative, although not that 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rates of psychiatric disorders in denmark urban-rural dwellers' well-being determinants: when the city size matters. the case of italy. city estimating the true global burden of mental illness disease burden and government spending on mental, neurological, and substance use disorders, and self-harm: cross-sectional, ecological study of health system response in the americas rural-urban differences in the prevalence of major depression and associated impairment rural/non-rural differences in rates of common mental disorders in britain: prospective multilevel cohort study the geographical distribution of insanity in the united states challenges to estimating the true global burden of mental disorders long-term exposure to fine particulate matter, residential proximity to major roads and measures of brain structure key: cord-293427-hwkmvo4p authors: zhang, li; ma, min; li, danfeng; xin, ziqiang title: the psychological typhoon eye effect during the covid-19 outbreak in china: the role of coping efficacy and perceived threat date: 2020-10-27 journal: global health doi: 10.1186/s12992-020-00626-8 sha: doc_id: 293427 cord_uid: hwkmvo4p background: the influence of covid-19 on mental health problems has received considerable attention. however, only a few studies have examined the relationship between exposure to covid-19 and mental health problems, and no empirical study has tested the mechanisms between them. methods: we conducted a survey in 31 provinces of china during 3–13 march 2020 to test the effect of the exposure level on mental health problems. our sample comprised 2987 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-19 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-19 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 11 june 2020, around 7.2 million confirmed cases globally, 84,652 in china, with 413,372 deaths (5.68%) had been reported by the who. reviews in the field of exposure to covid-19 and mental health problems have called for research to test the relationship between them and to identify the mechanism underlying this relationship [26, 51, 52] . the present study examined the risk perception factors that may explain how the level of exposure to covid-19 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 2002, the middle east respiratory syndrome coronavirus (mers-cov) in 2012, the west africa ebola virus disease (evd) pandemic in 2013-2016, and the global covid-19 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 [10] . during the west africa evd pandemic, there were increasing risks for new-onset psychological distress and psychiatric disorders [37] . psychosocial effects include adjustment disorders, symptoms of ptsd, anxiety, and depression [18, 22, 32] . to date, several studies have indicated the influence of covid-19 on mental health problems. for instance, the pandemic has burdened a major psychological stress on the medical workforce [28] and could cause distress and leave many people vulnerable to mental health problems and suicidal behavior [13] . thus, the influence of covid-19 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 [2, 27, 35, 42] . specific to covid-19, some studies have revealed that risk perception, health anxiety, social media use and more media engagement are predicators to mental health problems [1, 4, 31] . 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 (1987) , 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 [25, 51] . studies have found that proximity to the center of the epidemic or devastated area was negatively related to anxiety levels [51] , epidemic-related safety and health concerns [26] . 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 [51] , during the sars epidemic [25] and in relation to leadzinc mining risk [53] . researchers have proposed three major possible explanations for this effect [52] . the first explanation is psychological immunization theory, which assumes that resistance to a stressful event is naturally acquired through repeated exposure [16] . people become desensitized by repeated exposure and can better prepare for stressful events. the second explanation is cognitive dissonance theory [8] . 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 [25, 26, 52] . 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 [25, 52] , 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 [39] that include "the process of collecting, selecting, and interpreting signals about uncertain impacts of events, activities, or technologies" ( [45] , p.1049). a meta-analysis by sheeran and his colleagues showed that risk perceptions have a close association with people's health behavior [36] . according to protection motivation theory (pmt [29] ;), 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 [16] . 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-19 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 [51] and epidemic-related safety and health concerns [26] . in this study, we assessed mental health problems using a questionnaire adapted from the psychological and behavioral questionnaire for sars [9] . 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-19 epidemic influences mental health problems. according to protection motivation theory, we hypothesized that the association between the exposure level during the covid-19 epidemic and mental health problems was mediated by both individuals' perceived threat of covid-19 risk and their coping efficacy (see fig. 1 ). 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-19 studies. these studies showed that the relatively high perceived threat (severity and vulnerability) of sars/covid-19 played a pivotal role in the development of fear for the pandemic [31] or psychological distress [5, 6, 48] and increased the odds of individuals having a high level of depressive symptoms 3 years later [27] . 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. 1 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 [34] . a crosssectional study of 415 respondents in a community health care setting showed that mental health status was negatively correlated with coping strategies, which can increase self-efficacy [38] . a systematic review article [19] 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 [33] because it can promote self-efficacy [30, 50] . to achieve the two aforementioned purposes, we conducted a survey in 31 provincial-level administrative divisions of china during 3-13 march 2020. 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 (3-13 march 2020). the platform is a usable platform for user studies [20, 44, 49] . in total, 3459 participants from 31 provincial-level administrative divisions took part in the survey. the data of 471 participants who did not complete the survey seriously (average answer time less than 200 ms per question or answering repetitively for every question) were excluded. the final number of effective samples was 2987. this study was approved by the school of sociology and psychology academic committee, central university of finance and economics. it takes around 10 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 [9] , 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-19. twenty-five items were categorized into five dimensions: depression (α =0.93; e.g., "i am easily fatigued and have difficulty recovering"), neurosism (α = 0.91; e.g., "i am interested in nothing"), phobia (α = 0.82; 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 = 0.93; e.g., "i have symptoms including rapid heartbeat, sweating and blushing"), and hypochondriasis (α =0.80; e.g., "i worry about being infected when i have related symptoms"). all the items were measured on 4-point scales from 0 to 3 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: 0-3). we averaged the ratings to obtain the scores for each dimension and the overall mental health score (α =0.969). the accumulative number of confirmed cases was regarded as an indicator to evaluate the severity of the covid-19 epidemic compared with other epidemic indicators (e.g., accumulative number of deaths, incidence rate, case fatality rate; see details in table 1 ). all epidemic data were acquired from the official website of the national health commission on march 2nd, 2020, and this website is the most authoritative website for information on the epidemic during the covid-19 in china. this study used the accumulative number of confirmed cases to represent the exposure level during covid-19, see details in table 2 . the perceived threat questionnaire was selfconstructed based on the model of risk perception by slovic [39] . this questionnaire was designed to reflect perceived vulnerability and perceived severity during the outbreak of covid-19. a total of six items were used to measure perceived threat initially. all the items were measured on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). item descriptions, and reliability and validity of variables can be seen in tables 3 and 4 . one item "i follow the official information released by the national health commission frequently" was removed due to its loading below 0.70 [14] , 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 4 . the coping efficacy questionnaire was adapted from the perceived coping efficacy questionnaire used by kim, sherman and updegraff [21] , 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-19. 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 5-point scale from 1 (strongly disagree) to 5 (strongly agree), and all of items have high reliability and validity, see details in tables 3 and 4 . the following covariates were included in the current study: data was analyzed using spss 21.0, 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 3.3 (smart pls gmbh). pls-sem has often been recommended for data analysis in the case of nonnormal data [14] . in this study, original number of cases in the 31 provincial regions had great variances, and it doesn't conform to a normal distribution. for example, hubei province had 67,217 accumulated cases of covid-19 in 2 march, while the accumulated cases in other 30 provincial regions were under 1500, see details in table 2 . significance testing at the 0.05 level (two-tailed) in pls-sem were generated by using 5000 subsamples. the fig. 2 was negatively related to mental health scores of people in 31 provinces in china, r = − 0.09, p < 0.001. the correlations among the exposure level, risk perception and mental health problems during covid-19 are presented in table 5 . the exposure level was negatively related to mental health problems, p< 0.001. moreover, perceived threat was positively correlated with mental health problems, and coping efficacy was negatively related to mental health problems, ps < 0.001. furthermore, the mediating effects of risk perception between exposure levels and mental health problems were tested using the pls-sem in smartpls. we generated 5000 bootstrapping subsamples from the original data set (n = 2987). table 6 displays the direct and indirect effects after controlling for age, gender, income, educational level, and occupation (as covariates). the model explained 23.4% variance in mental health problems. as shown in fig. 3 , 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-19 in china influenced mental health problems. the results showed that the exposure level to covid-19 in china was negatively associated with mental health problems related to covid-19. specifically, the higher the exposure level to covid-19, the better mental health was. more importantly, this study is the first to reveal the mechanism by which the level of exposure to covid-19 is linked to mental health problems related to covid-19. specifically, perceived threat our finding of less serious mental health problems related to covid-19 for people with higher exposure levels to covid-19 in china confirms the psychological typhoon eye effect rather than the ripple effect. this finding is consistent with several previous studies [25, 51] 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 [11] . 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 [11] . according to our findings, the underlying mechanism is that coping efficacy mediates the negative relationship between the level of exposure to covid-19 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 [25, 52] , 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 [12, 46] . 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 [17, 21, 40] . 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., [3, 19, 50] ) and that response efficacy is positively correlated with health behavior (e.g., [15, 43] ). this study also showed that the perceived threat of covid-19 was positively related to mental health problems related to covid-19, which is consistent with previous evidence in relation to sars (e.g., [5, 6, 48] ). furthermore, perceived threat mediated the positive relationship between the level of exposure to covid-19 and mental health problems related to covid-9. 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 [47] . 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 3-13 march 2020 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-19, it might have made people understand the threat of the situation [7] . however, when constantly seeing news and reports highlighting the threat of covid-19, people will start to suffer from stress and anxiety [7] . 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-19 demands dynamic balance between perceived threat and coping efficacy [7, 47] . 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-19 in china and demonstrated the mediating role of coping efficacy and perceived threat between exposure to covid-19 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 1 to 4 years [23, 41] . medical staff who performed mers-related tasks showed the highest risk of posttraumatic stress disorder symptoms even after time had elapsed [24] . therefore, although we observed a negative correlation between the level of exposure and mental health problems, we do not suggest stopping or reducing 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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: 12 june 2020 accepted: 29 september 2020 key: cord-331338-oegiq363 authors: cluver, lucie title: solving the global challenge of adolescent mental ill-health date: 2020-06-23 journal: lancet child adolesc health doi: 10.1016/s2352-4642(20)30205-4 sha: doc_id: 331338 cord_uid: oegiq363 nan in the lancet child & adolescent health, daniel michelson and colleagues 1 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. 1 these services are designed as a stepped series of interventions to be implemented at low cost, by lay workers, and at scale. 2 in low-income settings globally, only a tiny fraction of adolescents with mental health distress will ever have access to psychiatric or psychological support. 3 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. 1 in very low-income urban indian schools, adolescents (aged 12-20 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 40-60% for evidence-based psychological treatments. the findings of this study have important and wideranging implications. as the authors discuss, 1 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 12 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. 1 a core aspect of this work is the conscious effort of mental health research and service provision in joining forces with the education sector. 4 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-19 epidemic has brought increased mental health distress among young people and new needs for mental health support, 5 as well as an anticipated economic downturn that will hit hardest in low-income and middle-income countries. 6 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, 2019, 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. 7 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. 8 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 ox1 2er, 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 42 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-19 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-300229-9qh7efs4 authors: inchausti, felix; macbeth, angus; hasson-ohayon, ilanit; dimaggio, giancarlo title: psychological intervention and covid-19: what we know so far and what we can do date: 2020-05-27 journal: j contemp psychother doi: 10.1007/s10879-020-09460-w sha: doc_id: 300229 cord_uid: 9qh7efs4 the coronavirus covid-19 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-19. 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-19, 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-19 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-19 restrictions have forced a move to online or technologically mediated delivery of psychological interventions. the coronavirus 2019 (covid-19) is a newly emergent infectious disease caused by the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus, originated in december 2019 from mainland china, with initial cases emerging from the city of wuhan, hubei province (cdcp 2020; li et al. 2020) . although most individuals diagnosed with covid-19 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. 2020 ). on 30th january 2020, world health organization (who) officially declared the covid-19 epidemic as a public health emergency of international concern, followed by designation as a pandemic on 11th march (i.e., presence of illness across multiple continents). the rapid spread of covid-19 places huge strain on capacity, responsiveness and resilience of public and private healthcare systems worldwide (emanuel et al. 2020; legido-quigley et al. 2020) . 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-19 are steadily increasing across all continents. on 11th april 2020, the cumulative total of individuals presenting with confirmed covid-19 was 1,648,365 people, with a total of 102,216 deaths (who 2020). in many countries testing is limited to hospitalised cases, therefore these numbers are likely to significantly underestimate the true prevalence of covid-19 in the population, given they do not cover mild presentation and asymptomatic cases. there is emerging evidence of the psychological impact of covid-19 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 2019). however, a significant percentage will experience intense emotional adjustment reactions, including fear of contagion (zhou 2020) , impact of prolonged quarantine xiao 2020) , 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. 2018) . in china, a survey of 1210 people found that 53.8% assessed the psychological impact of the situation as moderate-severe, 16.5% reported moderate to severe depressive symptoms, 28.8% moderate to severe anxiety symptoms, and 8.1% moderate to severe stress levels. most respondents (84.7%) spent between 20 and 24 h a day confined at home and the main concern (75.2%) was that his/her relatives would become infected with covid-19 . 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-19 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. 2020) . 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 2015; lee et al. 2018) . 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 2014) . this group may not emerge immediately within the pandemic, and presentations may only become apparent after several months, even after the incidence of covid-19 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. 2007 ), 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. 2002) . 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-19 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 (2020) highlight, specialized psychological intervention for covid-19 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-19 presentations (mohammed et al. 2015) . 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: 1. 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. 2020 ). 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 2018). 2. next it is important to engage emotionally vulnerable groups, especially people with previous psychopathology. the main goal here is to support individuals undergoing covid-19 treatment or preventative quarantine. the mental health symptoms of this group of patients with covid-19 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-19 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-19, 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. 2020 ). 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. 3. 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 2018). 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 2014 (nice , 2018 . 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 2018) . 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 2012) ; and guarding against the development of interventions for those that have recovered from covid-19 that stigmatize or block access of the to a new functional identity as survivors of the pandemic (muldoon et al. 2019) . going forward it is also crucial to ensure individuals affected by covid-19 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-19 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-19 and consistent with a social determinants of mental health model (e.g., lund et al. 2018 ). in organizing psychological assistance within and across various stages of the pandemic, we highlight four major challenges: 1. 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. 2015; shultz and neria 2013) . in china, the scarcity of human resources led to individual professionals accumulating multiple responsibilities, reducing the effectiveness of their interventions (duan and zhu 2020) . 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. 2. societal underestimation of the (short-and long-term) psychological consequences of pandemics and, consequently, limited resources to cope with them (bitanihirwe 2016). 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. 2015) . although the international covid-19 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 2020). in china, the progression of covid-19 aggravated the mental health of infected patients, the general population and health professionals (duan and zhu 2020). 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. 3. poor planning and coordination of psychological interventions, especially when they are applied at different levels and by different professionals (zhang et al. 2020 ). in china, at the start of the covid-19 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. 4. 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 2018; ogden 2019). 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 2019) 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 2000) 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. 2015) , 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 2000; inchausti et al. 2019 ). 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. 2015) . 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. 2018) . 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 24:7 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 1971) 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-19 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-19, 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-19 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 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cord-304510-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: 2020-10-06 journal: eur arch psychiatry clin neurosci doi: 10.1007/s00406-020-01196-x sha: doc_id: 304510 cord_uid: sfhwaqfr due to the ongoing covid-19 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 22, 2020 (prospero registration-no.: crd42020180043). 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 6807 screened articles, 25 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 1 week or longer. effect sizes were summarized for depressive disorders (odds ratio 2.795; 95% ci 1.467–5.324), anxiety disorders (odds ratio 2.0; 95% ci 0.883–4.527), and stress-related disorders (odds ratio 2.742; 95% ci 1.496–5.027). 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 (10.1007/s00406-020-01196-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 [1] . 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 [2] [3] [4] . 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 [5] . the authors concluded that important stressors were longer quarantine electronic supplementary material the online version of this article (https ://doi.org/10.1007/s0040 6-020-01196 -x) contains supplementary material, which is available to authorized users. duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma [5] . findings suggest that both containment strategies, quarantine and isolation, have negative impacts on psychological outcomes related to a broad spectrum of psychosocial stressors [2] [3] [4] [5] . 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-19 pandemic. an unprecedented number of people worldwide is affected by quarantine or isolation [6] . 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 [4] . the world health organization (who) has included covid-19 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 [7] . containment strategies are among the main countermeasures in this context [1] and systematic investigation of evidence concerning their psychological effects is urgently in need. single studies and reviews [4, 5] suggest an increased risk of negative psychological outcomes in persons under quarantine or isolation, but others presented partially contradicting results [8, 9] . furthermore, prevalence estimates point towards elevated levels of adverse outcomes in quarantined or isolated populations [4] , 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.: crd42020180043). methods followed guidelines by the cochrane collaboration for the conduction of systematic reviews [10] . we searched pubmed, psycinfo, and embase databases for studies with no restrictions, from the beginning of the searched time period and until april 22, 2020, 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 1. 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-19 [7] . 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 x9.3 (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 16.12, microsoft corporation, usa) followed recommendations by the cochrane collaboration handbook [10] 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: (1) continuous measures (mean scores), (2) 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) [11] as recommended by the cochrane handbook [10] (table 1) . 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 95% 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 [10] . 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 95% 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 [10] (three-level meta-analytic approach). heterogeneity among studies was quantified with the i 2 statistic. analyses were conducted according to the cochrane collaboration handbook [10] and using comprehensive meta-analysis v3 (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 6807 articles, 44 full-texts were assessed for eligibility. of these, 25 studies, published between 1998 and 2018, were eligible for quantitative synthesis (fig. 1 ). 16 studies observed isolation procedures, 8 studies observed quarantine procedures and one study observed quarantine and isolation procedures. mean length of containment measures ranged from 1 to 31.5 days (table 1) . three additional studies provided data on determinants only and were not included in quantitative synthesis [12] [13] [14] . pre-defined primary outcomes were depression, anxiety, and stress-related disorders. figure 2 presents effect sizes from all studies providing data for these outcomes. secondary outcomes were all other mental health outcomes, as presented in fig. 3 . 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. 4) . compared to non-quarantined/-isolated controls, individuals experiencing isolation or quarantine were at higher risk of depressive disorders (or 2.795; 95% ci 1.467-5.324; i 2 : 91.1%), anxiety disorders (or 2.0; 95% ci 0.883-4.527; i 2 : 86.5%), and stress-related disorders (or 2.742; 95% ci 1.496-5.027; i 2 : 90.0%). final ratings after assessment of methodological quality of included studies are summarized in table 1 . 14 out of 25 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. 2 ). determinants of psychological outcomes, reported to reach statistical significance in the primary studies, were: (results are from 1 study, if not otherwise specified). younger age was associated with higher risk for stressrelated disorders/ptsd (3 studies [15] [16] [17] ), whereas persons > 55 years were at higher risk for depression [18] . women were at higher risk for depression [18] , ptsd [16] , and general mental health impairments [8] (1 study each), while men were found to be at higher risk for (non-psychotic) psychological disorder of any kind [19] and at higher risk for alcohol use disorder [20] (1 study each). lower levels of education were associated with more severe symptoms of stress-related disorders/ptsd [15] and higher risk of depression [18] (1 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 (2 studies [18, 21] ), anxiety [13] , anger [13] , symptoms of stress-related [15] , and unspecified psychological disorders [19] (1 study each). lower income was also associated with higher persistence of symptoms of ptsd over 3 years [17] . interestingly, higher household income was associated with higher risk of alcohol use disorder [20] . low levels of social capital, lower perceived social support, and lower neighborhood relationships were associated with higher levels of depression (2 studies [21, 22] ) as well as anxiety, stress, and poor sleep quality (1 study [23] ). being single also determined higher levels of depression [24] and higher persistence of ptsd symptoms over 3 years [17] (1 study each). health care workers (hcw) experienced higher levels of stigmatization [25] . 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 [13] . previous mental illness and psychiatric inpatient admission was associated with greater anxiety (2 studies [13, 26] ) and anger [13] levels. a history of trauma determined higher risk of depression [24] . 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 [20] . lower perceived current health status was associated with higher levels of depression [21] . 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 [13, 19] . 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 [13] , depression (2 studies [21, 24] ), stress-related disorders/ptsd (3 studies [14, 17, 27] ), emotional exhaustion (2 studies [25, 28] ), insomnia [25] , alcohol use disorder (aud) [20] , and any psychological disorders [19] . 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 [27] . perception of the risk of health hazards due to infection was associated with a higher risk of symptoms of stress-related disorders/ptsd [8] . for isolated/quarantined individuals, dissatisfaction with containment measures, supply, or the relationship to healthcare-personnel was associated with higher levels of anxiety and anger [13] , stress-related disorders/ptsd (2 studies [8, 14] ) and lower general mental health [8] . 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 [28] . increased length of quarantine or isolation positively correlated with higher levels of anger (2 studies [13, 28] ), anxiety [13] , avoidance behavior [28] and stress-related disorders/ ptsd [14] . independent of infection status, isolation was found to have negative psychological effects after 1 and particularly after 2 weeks [12] . some studies [29, 30] did not find negative mental health effects in isolation of 1-3 days duration, whereas others [26, 31, 32] did. altruistic acceptance of infection-risk was reported to be protective against depression [24] and stress-related disorders/ptsd [17] . increased perceived stress was associated with higher levels of depression and anxiety [22] . selfesteem and sense of control were inversely correlated with anxiety and depression [33] . children of parents with symptoms of ptsd had themselves an elevated risk for ptsd [16] . 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 14 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 [5] . in the same vein, cases of suicide associated with quarantine were reported during an outbreak with severe acute respiratory syndrome (sars) outbreak 2012-2013 [34]. purssell et al. previously reported increased rates of anxiety and depression in hospital-isolated patients [2] . 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 [29, 30] did not find negative mental health effects in isolation of 1-3 days duration, but others [26, 31, 32] did. after periods of 1 and particularly of 2 weeks, however, evidence for adverse mental health effects of isolation and quarantine becomes increasingly solid [12, 14, 28] . 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 [35] . our review suggests that lower levels of education [15, 18] , low income and financial loss [13, 15, 18, 19, 21] , and lack of social networks are important determinants of negative psychological outcomes including depression, anxiety, and stress-related disorders, partly persisting over years [17] . 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 [26, 27] . 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 [36] 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 [13, 28] . this is of particular relevance during the current worldwide covid-19 pandemic, as could be shown by concerns of increasing domestic violence and child abuse based on initial reports in populations affected by covid-19 quarantine in asia and europe [37, 38] . a major important finding is the elevated risk of negative psychological effects for healthcare workers, particularly those with exposure to infected patients [8, 13, 14, 17, 19, 21, 24, 25, 27, 28] . awareness has to be drawn to the finding [28] 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 (1) partial use of cross-sectional study designs, thus making temporality of events difficult to assess, (2) lack of power, and (3) 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-19 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 [14, 39, 40] , 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) [41] or the international statistical classification of diseases and related health problems (icd) [42] . 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 [5] . 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-19 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 [14] . these effects might even be stronger in the ongoing covd-19 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 [5] . 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 [5] . 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 265 (crc-trr 265). henrik walter has received funding from the european union's horizon 2020 research and innovation programme under grant agreement no 777084. 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 4.0 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/4.0/. learning from sars: preparing for the next disease outbreak-workshop summary impact of isolation on 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(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-333187-8p61xten 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: 2020-08-17 journal: psychiatry res doi: 10.1016/j.psychres.2020.113394 sha: doc_id: 333187 cord_uid: 8p61xten 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 = 25) 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 41% of those with mental health disorders access treatment the year prior and only 33% receive minimally adequate treatment, if any treatment at all (wang et al., 2005) . 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., 2004) . problems accessing mental health care persist for some in the department of veterans affairs (va; keller & tuerk, 2016; maguen et al., 2012) . 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, 2014; goldberg et al., 2019) 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, 2016; seal et al., 2010; teich et al., 2016) . veteran barriers to care have been specified (e.g., bovin et al., 2019; possemato et al., 2018; tanielian & jaycox, 2008) , 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, 2014), va has aggressively pursued the embedding of mental health specialists in primary care (department of pilot trial of cast among veterans veterans affairs, 2015) . 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, 2005) . 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., 2019; leung et al., 2018) . technology-based interventions can play an important role in integrated mental health stepped-care approaches to treatment (e.g., espie, 2009; green & iverson, 2009 ), 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., 2014) . 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., 2013; marshall et al., 2010; naragon-gainey, 2010) . cast is a fully computerized, 45-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,2004) . cast has demonstrated efficacy in reducing symptoms of ptsd, anxiety, depression, and suicidal ideation in multiple randomized controlled trials (schmidt et al., 2014 (schmidt et al., , 2017 short et al., 2017a) , but limited research exists among veterans. a secondary analysis (short et al., 2017b) of cast users from a previous randomized clinical trial (schmidt et al., 2014) found that the sub-set 16 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 16 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., 2007) , and are arguably an ideal population and setting to deploy a first-step intervention, a single-session, transdiagnostic intervention (bower & gilbody, 2005) 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: (1) collect user feedback from veterans regarding the acceptability/usability of cast and potential areas of improvement for use with veterans, and; (2) 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 = 25) 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 (1) enrolled in primary care at the va facility and (2) scored at least 1 sd above the community mean on the anxiety sensitivity index-3 (asi-3) cognitive subscale (score of > 7; taylor et al., 2007) . exclusionary criteria included: (1) age greater than 65, (2) women who are pregnant, (3) history of stroke, seizure, irregular heartbeat, or heart failure, (4) 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 51.44 years old (sd = 9.49) and the majority identified as male (84%) and caucasian (72%). full sample demographics can be found in table 1. -3 (asi-3) . the asi-3 is an 18-item questionnaire used to assess fear of anxiety-related sensations and has been validated in community and clinical samples (taylor et al., 2007) . participants rate the degree to which they agree with each item on a 5-point scale ranging from "very little" to "very much". higher scores indicate a greater fear of anxiety-related sensations. the asi-3 was administered at baseline, post-intervention, and at 1-month follow-up. in the current sample the asi-3 demonstrated excellent internal consistency at baseline (α = .93). the gad-7 (spitzer et al., 2006 ) is a 7item questionnaire designed to assess anxiety symptoms. the gad-7 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 4-point scale ranging from "not at all" to "nearly every day". the gad-7 was administered at baseline and at the 1-month followup. in the current sample the gad-7 demonstrated good internal consistency at baseline (α = .87). the phq-9 (spitzer et al., 1999 ) is a 9item questionnaire designed to assess symptoms of depression. the phq-9 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 4-point scale ranging from "not at all" to "nearly every day". the phq-9 was administered at baseline and at the 1-month follow-up. consistent with many previous studies (e.g., louzon et al., 2016; pilot trial of cast among veterans al., 2018), item 9 ("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-9 demonstrated excellent internal consistency at baseline (α = .91). the pcl-5 (weathers et al., 2013 ) is a 20item questionnaire designed to assess the symptoms of ptsd. the pcl-5 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 5-point scale ranging from "not at all" to "extremely". the pcl-5 was administered at baseline and at the 1month follow-up. in the current sample the pcl-5 demonstrated excellent internal consistency at baseline (α = .93). the sus is a widely used, 10-item self-report questionnaire that assesses the usability of technology systems (brooke, 1996) . participants rate their experience with the usability of the computer program on a 5-point scale ranging from "strongly disagree" to "strongly agree". the sus was administered post-intervention and demonstrated good internal consistency (α = .83). the aq is an 8-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., 2017a; raines et al., 2020; short et al., 2017b) . the aq was administered post-intervention. two qualitative interviews were conducted (at post-intervention and 1-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 2-5 minutes including completion (written or verbal) of the asi-3 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 (45 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., 2017 ) by an experienced doctoral-level qualitative researcher. the entire in-person visit lasted approximately 2 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 30-45 minutes. program consists of 50 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, 60-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 = 25) paired samples t-tests were utilized. changes in as and symptoms over the period from baseline to follow-up (n = 21), were examined with repeated measures ancovas (baseline and 1-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 1-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, 2002) . 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 2 . the majority of participants rated cast as at least "moderately easy" to understand (88%), "moderately easy" or "easy" to follow (88%), at least "moderately helpful" (88%), at least "somewhat engaging" (88%), "somewhat interesting" or "very interesting" (96%), and at least "somewhat applicable" to daily life (84%). the majority of participants also found cast to be "somewhat applicable" or "very applicable" to stressors during military service (72%). eighty-eight percent of participants reported that they were "somewhat likely" or "very likely" to use the information and techniques learned. sus scores (m = 83.00, sd = 13.75) demonstrated good-to-excellent usability and were higher than average sus scores found through meta-analytic work (m = 70; bangor et al., 2008) . 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 3 ). 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-3 total (δm = 7.60, δsd = 11.25; t (24) = 3.38. p = .002; d = .68), asi-3 physical (δm = 2.44, δsd repeated measures ancovas, controlling for mental health appointment attendance between study visits, revealed medium-to-large effects on asi-3, gad-7, phq-5, pcl-5 and suicidal ideation (phq-9 item 9) from baseline to 1-month follow-up (see table 4 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., 2008) . these results are consistent with prior work examining acceptability of cast among veterans in an academic setting (short et al., 2017b) and among veterans in a va opioid use disorder intensive outpatient program (raines et al., 2020) . 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, 2017b; perry et al., 2017; powell et al., 2019) , 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, 2018) . 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., 2019) . 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., 2017a) . 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-19. regarding the intervention's efficacy, the current study saw significant, medium-sized decreases in as between baseline and posttest (d = .68) and baseline to 1-month follow-up (d = .61). these effect sizes are commensurate with studies examining cast among undergraduate rct; d = .81 ) and community participants (schmidt et al., 2014; rct; d = .57 ) in an academic setting as well as among veterans in a va opioid use disorder intensive outpatient program (raines et al., 2020 ; open pilot; glass's δpre of 0.61). 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., 2014; schmidt et al., 2017) . 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., 2010) . 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., 2015) and identify barriers to receiving mental healthcare within a va setting (cheney et al., 2018) , 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, 2014) 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, 2005) 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 (56%) or previously engaged in psychotherapy (40%). 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., 2016; n= 447,245) of veterans found that a single item measure of si significantly predicted suicide mortality (hr = 1.47), 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., 2017a) , 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., 2017a) , 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 4 . changes in clinical variables from baseline to 1-month follow-up note. asi-3 = anxiety sensitivity index -3; gad-7 = generalized anxiety disorder -7; phq-9 = patient health questionnaire -9; pcl-5 = ptsd checklist for dsm-5. 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 5135 transgender veterans receiving healthcare in the veterans health administration: a casecontrol study veteran-centered barriers to va mental healthcare services use vha handbook 1160.01: 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-9 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 103 788 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-7 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-3 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-5 (pcl-5) 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-335549-fzusgbww authors: newby, j.; o'moore, k.; tang, s.; christensen, h.; faasse, k. title: acute mental health responses during the covid-19 pandemic in australia date: 2020-05-08 journal: nan doi: 10.1101/2020.05.03.20089961 sha: doc_id: 335549 cord_uid: fzusgbww the acute and long-term mental health impacts of the covid-19 pandemic are unknown. the current study examined the acute mental health responses to the covid-19 pandemic in 5070 adult participants in australia, using an online survey administered during the peak of the outbreak in australia (27th march to 7th april 2020). self-report questionnaires examined covid-19 fears and behavioural responses to covid-19, as well as the severity of psychological distress (depression, anxiety and stress), health anxiety, contamination fears, alcohol use, and physical activity. 78% of respondents reported that their mental health had worsened since the outbreak, one quarter (25.9%) were very or extremely worried about contracting covid-19, and half (52.7%) were worried about family and friends contracting covid-19. uncertainty, loneliness and financial worries (50%) were common. rates of elevated psychological distress were higher than expected, with 62%, 50%, and 64% 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-19 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-19) 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-19 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-19 pandemic. 6 levels in the current cohort. we also expected people with lived experience of prior mental health diagnoses 122 would have higher rates of distress and would be vulnerable to poorer mental health during the current 123 pandemic. finally, we predicted that engaging in precautionary hygiene behaviours would be associated 124 with lower distress. 125 7 status (including whether they had recently lost their job due to , the industry of their main job, 147 and the frequency at which they had worked from home during the past week (not at all, a little, sometimes, 148 most of the time, all of the time). 149 participants were asked whether they had a chronic illness (yes, no, unsure, prefer not to say) , and 151 completed a single-item measure assessing their self-rated heath (idler & benyamini, 1997) , with responses 152 on a 5-point scale from poor to excellent. participants were asked whether they had ever been diagnosed 153 with a mental health problem such as depression and anxiety (yes, no, unsure, prefer not to say) , and 154 whether they were currently receiving treatment for a mental health problem including medications, 155 counselling, or psychological therapy (yes, no, unsure, prefer not to say) . 156 participants were asked to complete single item measures of i) how lonely they were feeling, ii) how 158 worried they were about their financial situation, and iii) how uncertain they were feeling about the future, 159 on a 5-point scale (not at all, a little, moderately, very, extremely). they were then asked to rate how the compulsion [24] , and iv) a specific measure of behavioural responses to the pandemic based on our prior 168 study [14] , and past research investigating behavioural responses to pandemics [25, 26] . finally, we assessed 169 physical activity levels using the physical activity vital sign [27] which assessed i) the number of days in 170 the past week they engaged in moderate to strenuous activity, and ii) the average number of minutes they 171 exercised at this level, and screened for hazardous alcohol use using the modified alcohol use disorders 172 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 8, 2020 . . https://doi.org/10.1101 identification test 28] . all questionnaire responses were anchored to the past week, except for 173 the audit-c (past month), and the padua contamination subscale (general). the mental health and lifestyle 174 questionnaires were administered in randomised in order to minimise responding biases. 175 participants were asked about their own covid-19 status (i have caught unsure, or other (open text) ). they also indicated 179 whether they were in self isolation (yes -i am in voluntary self-isolation, yes -i am in forced self-isolation, 180 no). participants were also asked i) whether any of their family or friends had contracted 181 no, unsure), and ii) how concerned or worried they were that their friends or family members would 182 contract covid-19 (not at all, a little concerned, moderately concerned, very concerned, extremely 183 concerned). 184 participants were asked five questions relating to their perceived risk from, and worry about, 185 covid-19. the first question assessed how concerned or worried respondents were about catching covid-186 19 on a 5-point scale (not at all concerned, a little concerned, moderately concerned, very concerned, 187 extremely concerned). they then rated how likely they thought it was that they would catch the virus on a 188 visual analogue scale (vas) from 0 (not at all likely) to 100 (extremely likely). they were asked how much 189 they thought they could do personally to protect themselves from catching the virus (perceived behavioural 190 control), on a 0 (couldn't do anything) to 100 (could do a lot) visual analogue scale. perceived illness 191 severity was assessed by asking respondents how severe they thought their symptoms would be if they did 192 catch covid-19 (response options were: no symptoms, mild symptoms, moderate symptoms, severe 193 symptoms, severe symptoms requiring hospitalisation, and severe symptoms leading to death). finally, 194 participants were asked about how much information they had seen, read or heard about coronavirus 195 (nothing at all, a little, a moderate amount, a lot). 196 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 8, 2020 . . https://doi.org/10.1101 to assess social distancing, hygiene and buying behaviours, participants were asked whether they 198 had engaged in a total of 16 behaviours during the previous week (see table 2 demographic characteristics of the sample are depicted in table 1 . overall, the sample was mostly female 206 (86%), identified as being caucasian (75%), mainly spoke english at home (91%), and ranged in age from 207 18 to over 75. participants were from various states and territories of australia, with the majority living in 208 the most populated states of new south wales, victoria or queensland. sixty five percent were working in a 209 paid job, and approximately one third were carers (for children, or people with a disability, illness, or the 210 elderly). respondents' self-rated health was measured on a scale from poor (1) to excellent (5), with a mean 211 of 3.0 (sd = 0.97). the majority of participants rated their health as 'fair' (24.4%), 'good' (37.7%), or 'very 212 good' (24.4%); relatively few participants rated their health as 'poor' (5.3%)' or 'excellent' (5.3%). 213 only eight participants (0.2%) reported that they themselves currently have or have had 9.2% 215 were unsure, and 1.2% suspected they had covid-19. approximately 4.8% reported their family or friends 216 had caught covid-19, and 8.2% were unsure. almost half (48.8%) reported being in voluntary self-217 isolation, 2.4% reported being in 'forced self-isolation' and 48.8% were not self-isolating. 218 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 8, 2020. . 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 8, 2020. . level of concern and worry about the possibility of contracting covid-19 was moderate (m = 2.84, 220 sd = 1.07, range 1-5, where 1 = not at all, 5 = extremely concerned). a small proportion reported being 'not 221 at all concerned' (7.6%), 35% reported being 'a little' concerned, 31.4% were 'moderately concerned ', 222 17.2% were 'very concerned', and 8.5% were 'extremely concerned' about contracting respondents' ratings of the perceived likelihood of contracting covid-19 was moderate (m = 48.25, sd = 224 24.84; scale from 0 to 100). perceived behavioural control, or the belief that personal protective behaviours 225 could help prevent infection, had a mean score of 71.64 (sd = 19.69). with regard to perceived severity of 226 symptoms if they caught coronavirus, only 0.3% of respondents indicated that they would experience no 227 symptoms; with mild (19.6%) and moderate (43.9%) symptoms most commonly expected. however, one in 228 three respondents perceived the illness severity to be high: with 20.1% indicating they thought they would 229 experience severe symptoms, severe symptoms requiring hospitalisation (12.0%), or severe symptoms 230 leading to death (4.1%). in terms of the amount of information participants had been exposed to about the 231 coronavirus in the past week, most participants (75%) reported having 'a lot' of exposure to information, 232 21.6% reported a 'moderate amount', whereas very few reported a little (3.3%) or no information at all 233 (0.1%). 234 participants' overall level of concern and worry about friends and loved ones contracting covid-19 was 236 moderate (m = 3.53, sd = 1.03, range 1-5, where 1 = not at all, 5 = extremely concerned). a small 237 proportion reported that they were 'not at all concerned' (1.6%), 16.5% reported being 'a little' concerned, 238 29.2% were 'moderately concerned', 33.1% were 'very concerned', and 19.6% 'extremely concerned' about 239 their friends or family members contracting covid-19. 240 the percentage of respondents who reported having engaged in a range of distancing and hygiene 242 behaviours during the past week is presented in table 2 . during the previous week, handwashing and social 243 distancing (avoiding social events and gatherings) were the most common behaviours. 244 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 246 outbreak, with 55.1% selecting 'a little worse', and 22.9% selecting 'a lot worse'. a small proportion 247 reported improvements in their mental health since the outbreak (5.5%) (see figure 1) . a chi square analysis 248 revealed that there was a significant difference in the impact of covid-19 on mental health for participants 249 with and without a prior mental health diagnosis ( 2 (4) = 141.44, p <.001), with 26.6% of those with a 250 prior mental health diagnosis saying their mental health had been 'a lot worse', relative to 13.4% in the 251 group without a mental health diagnosis. 252 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 3 shows the proportion of participants who scored across the severity categories of the dass-256 21 subscales. only 38.2% of respondents scored in the normal range for depression, 50.2% in the normal 257 range for anxiety, and 45.5% for stress. in contrast, 37.1%, 29.1%, and 33.6% fell in the mild to moderate 258 range for depression, anxiety, and stress respectively, whereas 24.1%, 20.3%, and 20.4% reported severe or 259 extremely severe stress levels. on the whiteley-6, 21.6% scored in the range indicating elevated health 260 anxiety. of the participants who had valid scores on the physical activity vital sign (n=4845), 42.7% met 261 national guidelines for 150 minutes of moderate to vigorous physical activity in the past week. on the 262 audit-c brief screener for alcohol use, approximately 52.7% showed hazardous drinking levels. 263 hazardous drinking levels were defined as an audit-c score of 3 or more for women and other genders, 264 and 4 or more for men [28, 29] . 265 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 8, 2020. . comparison between people with and without prior mental health diagnosis 266 people with and without a self-reported history of mental health diagnosis were compared in their severity of 267 covid-19 fears, mental health, distress, health anxiety, alcohol use, contamination fears, and physical 268 activity. people with a previous self-reported mental health diagnosis reported higher uncertainty, loneliness, 269 financial worries, covid-19 fears (self and others), believed they were more likely to contract 270 had lower perceived behavioural control, had higher rates of psychological distress, health anxiety and 271 contamination fears, and lower physical activity than those without a self-reported mental health diagnosis 272 history. there were no differences in alcohol use between these groups (see table 4 ). 273 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 274 in self-isolation reported higher uncertainty, loneliness, financial worries, and covid-19 fears (self and 275 others), rated the symptoms of covid-19 as more serious, but believed they were less likely to contract 276 covid-19, and perceived more behavioural control over covid-19. they also had higher rates of 277 psychological distress, health anxiety and contamination fears, and lower alcohol use than those not in 278 isolation. there were no differences in physical activity between these groups (see table 5 ). 279 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 8, 2020. . separate linear regression analyses were conducted to explore the demographic, occupational, and 281 psychological predictors of dass-21 depression, anxiety and stress severity (see final model in table 8 ). 282 we entered demographic predictor variables (gender, age, occupational status, education, aboriginal and/or 283 torres strait islander and carer status) in the first step. in the second step, we entered general health 284 variables including chronic illness, mental health diagnosis history, and self-rated health. in the third step, 285 we entered uncertainty about the future, loneliness, worry about finances. in the final step, we added 286 covid-19 variables (whether they were in self-isolation, hygiene behaviours, exposure to covid-19 287 information, risk perceptions including perceived likelihood, perceived control, and severity of illness, 288 concern/worry about contracting covid-19, and concern/worry about loved ones contracting depression. demographic variables accounted for 10.8% of the variance (r 2 change =0.11, se=10.02, f change 290 (18, 4971), = 33.32, p <.001). entering the mental health diagnosis, chronic illness, and self-rated health 291 variables accounted for 9.5% of additional variance (r 2 change =0.095, se=9.47, f change (3, 4788), = 191.73, p 292 <.001). in the third step, entering mental health variables accounted for 27.5% unique variance (r 2 293 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 8, 2020. . change =0.28, se=7.66, f change (3, 4785), = 845.35, p <.001). finally, the covid-19 variables accounted for 294 0.7% unique variance (r 2 change =0.007, se=7.61, f change (3, 4777), = 8.02, p <.001). the final model is 295 presented in table 8 and accounted for 48.5% of the variance in depression scores. 296 controlling for the other variables in the model, being female, more well educated, older, and having better 297 self-rated health were all associated with lower depression, whereas being unemployed, a student, retired, 298 carer or stay at home parent were associated with higher depression. mental health and chronic illness 299 diagnoses were associated with higher depression, as were increased uncertainty about the future, loneliness, 300 and financial worries. of the covid-19 variables, higher worry about covid-19 and perceived 301 behavioural control over covid-19 infection were associated with lower depression, whereas perceiving 302 higher illness severity was associated with higher depression. 303 anxiety. in the first step, demographic variables accounted for 10.7% of the variance in anxiety scores ( controlling for other variables in the model, being female, non-binary or different gender identity, and being 312 aboriginal and/or torres strait islander were predictors of higher anxiety. older age, and more well 313 educated (certificate, degree or higher) were predictors of lower anxiety. in contrast to depression, only 314 being a student predicted worse anxiety. having a chronic illness, and prior history of mental health 315 diagnosis were associated with higher anxiety, whereas better self-rated health was a predictor of lower 316 anxiety. similar to depression, increased uncertainty about the future, loneliness, and financial worries were 317 also associated with higher anxiety. of the covid-19 variables, more hygiene behaviours, worry about 318 covid-19, worry about loved ones contracting covid-19, and higher perceived illness severity were 319 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 8, 2020. . predictors of higher anxiety, whereas increased exposure to covid-19 information, and perceived control 320 over stress. in the first step, demographic variables accounted for 10.8% of the variance in anxiety scores (r 2 322 change =0.11, se=8.99, f change (18, 4791) controlling for other variables in the model, identifying as non-binary or different gender identity, 330 aboriginal and/or torres strait islander, predicted higher stress. being more well-educated with a trade 331 certificate, and older age, were predictors of lower stress. being a stay at home parent was a predictor of 332 higher stress. having a chronic illness, and prior history of mental health diagnosis were associated with 333 higher stress, whereas better self-rated health was a predictor of lower stress. increased uncertainty about the 334 future, loneliness, and financial worries were also associated with higher stress. of the covid-19 variables, 335 more hygiene behaviours, worry about loved ones contracting covid-19, and higher perceived likelihood 336 of contacting covid 19 were predictors of higher stress. higher perceived control over covid-19 337 predicted lower stress. 338 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 8, 2020. . this survey presents the first insight into how the covid-19 pandemic has impacted the mental 340 health of people living in australia, in a sample of 5070 individuals. rapidly disseminating an online survey 341 enabled us to assess a large number of participants during the peak of the pandemic in australia to identify 342 fears and acute distress and identify the relationship between demographic and psychological predictors of 343 mental health. while very few individuals reported that they (0.15%) or their family/friends (4.8%) had 344 contracted covid-19, one quarter (25.9%) of respondents were very or extremely worried about 345 contracting covid-19, and over half (52.7%) were very or extremely worried about their family and friends 346 contracting covid-19. almost four in five participants reported that since the outbreak their mental health 347 had worsened, with over half (55%) saying it had worsened a little, and almost a quarter of respondents 348 (23%) saying it had worsened a lot. a small minority reported better mental health (4.8%). results showed 349 that many people are experiencing high levels of uncertainty about the future (80%), and half of respondents 350 reporting moderate to extreme loneliness and worry about their financial situation. given loneliness, social 351 isolation, and financial stress are significant risk factors for poor mental and physical health, and risk factors 352 for suicidal ideation [e.g., 19, 20, 30] , these findings are concerning. 353 to rapidly respond to the evolving covid-19 situation, we administered online validated self-report 354 questionnaires rather than diagnostic interviews. it is important to note that these questionnaires assessed 355 symptoms of distress during the past week and should not be taken as indicative of a 'diagnosis' of a 356 depressive or anxiety disorder. we found higher than expected levels of acute distress based on research in 357 china during the covid-19 pandemic [8] , and compared to normative data [22, 31] . between 20.3-24.1% 358 of the current sample were experiencing severe or extremely severe levels of depression, anxiety and stress, 359 and a further 18-22% moderate symptoms. only 38% of the current sample had normal depression, 50% had 360 normal anxiety, and 46% had normal stress levels, whereas in the chinese sample reported by wang et al. 361 [8] 64-69% had normal anxiety, stress and depression on the dass-21. these differences may be due to the 362 high proportion of people with pre-existing mental health diagnoses (70%) in our sample, which have been 363 shown to be a vulnerable group [8, 10] , or because of the significant proportion with a self-reported chronic 364 illness (38%), who may be more susceptible to more severe covid-19 disease, and therefore more 365 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 8, 2020. . distressed. having a personal history of chronic illness was a consistent predictor of higher depression, 366 anxiety and stress, whereas better self-rated health was associated with better mental health. compared to 367 the australian population, this sample appeared to have poorer health, with 30% reported being in fair or 368 poor health (compared to 15% in the australian population), and 30% reporting being in very good or 369 excellent health (compared to 56% of australians) [32] . 370 our data gave some insights into other demographic variables which predict higher psychological 371 distress. specific occupational factors predicted higher distress levels: student status (depression and 372 anxiety), being an at home parent (depression and stress), a carer or retired (predicted higher depression), 373 whereas education was associated with lower psychological distress. in contrast to past research, identifying 374 as female predicted lower depression, however identifying as non-binary or a different gender identity was 375 associated with higher self-reported anxiety and stress. identifying as aboriginal or torres strait islander 376 also predicted worse anxiety and stress levels. these groups may be particularly vulnerable during the 377 current pandemic, and longitudinal research is needed to explore the longer term predictors of poorer mental 378 health over time. 379 our results confirm fears about the potential impact of the covid-19 pandemic on people with lived 380 experience of mental illness [7] . participants with a self-reported history of mental health problems were 381 more afraid of covid-19 and more worried about their loved ones contracting covid-19, had higher 382 distress, depression, anxiety, health anxiety and contamination fears, and higher rates of elevated health 383 anxiety (26% versus 11%) than those without pre-existing mental health diagnoses. relative to those 384 without mental health issues, a greater proportion of people with self-reported mental health problems had 385 elevated health anxiety (26% versus 11%), and said their mental health had been 'a lot worse' since the 386 outbreak (26% versus 13%). having a history of mental health issues was a consistent predictor of higher 387 depression, anxiety and stress. 388 because we did not collect any information about the history and nature of these mental health 389 diagnoses, we cannot determine whether these individuals had higher distress prior to the pandemic, or 390 whether distress increased as a result of the pandemic, due to inability to access usual supports, social 391 isolation or loneliness [7] . however, our findings highlight the need for proactive mental health 392 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 8, 2020. . interventions for those who are experiencing elevated symptoms of depression, anxiety and stress during the 393 current covid-19 pandemic, regardless of whether the distress is an exacerbation or recurrence of pre-394 existing mental health concerns, or new onset. digital interventions, which have been shown to be highly 395 effective and cost-effective for depression and anxiety treatment [33] will be crucial to respond to these 396 ongoing mental health concerns, as they have capacity to deliver high quality interventions for distress at 397 scale, and to those in social isolation who are unable to attend face-to-face services [7, 34] . 398 this study provides new knowledge about the rates of health anxiety during the covid-19 399 pandemic. over one in four (26%) of people with a prior history of mental health issues, and 11% of those 400 without pre-existing mental health issues reported elevated health anxiety in the past week, which is higher 401 than rates of health anxiety in the general australian population (3.4% [35]), and closer to the rates of health 402 anxiety observed in general practice (10%) and outpatient medical clinic settings (20-25%) [36] . while these 403 symptoms are not necessarily indicative of illness anxiety disorder, high health anxiety is likely to have 404 significant ramifications for health service utilisation. responses to health anxiety vary substantially, with 405 responses ranging from a complete avoidance of doctors, hospitals, and medical settings due to fear, to the 406 other end of the spectrum of excessive, repeated, and unnecessary health service use, diagnostic testing, 407 emergency visits and paramedic calls [37] . proactive treatment of health anxiety with digital interventions 408 may also be needed should these symptoms persist [38, 39] . 409 in prior research, risk perceptions, including the perceived risk of contracting the virus, perceived 410 control over the virus, and the perceived seriousness of the symptoms have been shown to be associated with 411 psychological distress, and behavioural responses to disease outbreaks. consistent with the findings of 412 sars pandemics, and our previous study, we found moderate perceptions of risk of contracting the virus. 413 participants rated on average that there was a 50% likelihood of contracting the virus personally, and higher 414 perceived risk was associate with higher depression and stress levels. in the current cohort approximately 415 one third of participants expected covid-19 to lead to severe symptoms (32.1%), and in some cases death 416 (4%), which is higher than in our previous study, where we found only 25% expected severe symptoms. the 417 expected severity of the covid-19 illness differs markedly to the reality for most people, as studies show 418 that 80% of people will experience no or mild symptoms [40] . these findings reinforce the need for 419 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 8, 2020. . education campaigns to address these misperceptions, especially as research has shown that these beliefs are 420 associated with engagement with distress. these risk perceptions explained a relatively small amount of 421 variance in the regression analyses, with perceived control over covid-19 a consistent predictor of better 422 mental health and higher perceived severity of illness associated with higher depression and anxiety. 423 however, it is important to note that other predictors, including loneliness, financial stress, uncertainty, 424 demographic factors, and prior history of mental and chronic illness were stronger predictors of distress. 425 similar to wang et al. [8] , some of the most common precautionary behaviours were avoiding 427 touching objects that had been touched by others, washing hands, and using hand sanitiser. participants also 428 commonly reported staying at home and avoiding social events and socialising with others outside of the 429 household. in contrast to media portrayals of panic buying, excessive purchasing behaviour was not 430 common. in previous research, higher engagement in hygiene behaviours, such as handwashing have been 431 associated with lower distress and anxiety, suggesting behavioural control may be protective for mental 432 health. however, in the current cohort we found some inconsistent results, with engagement in more hygiene 433 behaviours associated with higher anxiety and stress levels (they were not associated with depression). 434 these findings differ to the findings of wang et al. [8] during the early stages of the epidemic in china, 435 where the use of precautionary measures, such as avoiding sharing utensils, hand hygiene and wearing 436 masks were associated with lower stress, anxiety and depression. however, the current findings are 437 consistent with some research from the sars epidemic, in which moderate levels of anxiety were 438 associated with higher uptake of precautionary behaviours [41] . it is possible that the association we found 439 was due to people who were higher in anxiety or stress using these behaviours in an attempt to control 440 anxiety. 441 finally, concerns have been raised about the potential impact of social isolation and quarantine on 442 physical inactivity, as well as increased alcohol use and abuse. on the audit-c brief screener for alcohol 443 use, approximately 52.7% met criteria for hazardous drinking levels, which is higher than the 42% found in 444 primary care samples in australia [42] and higher than usa-based population samples (35 %-45%) [43] . 445 however it is important to note that participants with a prior experience of mental health problems had 446 lower rates of hazardous drinking, and lower rates of inactivity. in the current sample, 42.7% met the 447 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 8, 2020. . world health organisation. coronavirus disease 2019 (covid-19) situation report expected impact of covid-19 on the mental health of health professionals. a 474 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 477 psychiatry psychological effects of the sars outbreak in hong kong on high-risk health care 479 workers long-term psychiatric morbidities among sars survivors. general hospital 481 psychiatry coping responses of emergency physicians and nurses to 483 the 2003 severe acute respiratory syndrome outbreak multidisciplinary research priorities for the covid-19 pandemic: a call for 485 action for mental health science. the lancet psychiatry immediate psychological responses and associated factors during the initial stage 487 of the 2019 coronavirus disease (covid-19) epidemic among the general population in china. int 488 impact of the covid-19 pandemic on mental health and quality of life 490 among local residents in liaoning province, china: a cross-sectional study a nationwide survey of psychological distress among chinese people in the covid-19 493 epidemic: implications and policy recommendations. general psychiatry factors associated with mental health outcomes among health care workers 495 exposed to coronavirus disease a longitudinal study on the mental health of general population during the covid-497 19 epidemic in china generalized anxiety disorder, depressive symptoms and sleep quality during 499 covid-19 epidemic in china: a web-based cross-sectional survey. medrxiv public perceptions of covid-19 in australia: perceived risk, 502 knowledge, health-protective behaviours, and vaccine intentions. under review psychological predictors of health anxiety in response to the 504 journal of clinical psychology in medical settings psychological predictors of anxiety in response to the h1n1 (swine flu) 506 pandemic. cognitive therapy and research coronaphobia: fear and the 2019-ncov outbreak how health anxiety influences responses to viral outbreaks like 510 covid-19: what all decision-makers, health authorities, and health care professionals need to 511 know loneliness in the general population: prevalence, determinants and relations to 513 mental health loneliness as a specific risk factor for depressive symptoms: cross-sectional 515 and longitudinal analyses a systematic review on health resilience to economic crises manual for the depression anxiety stress scales comparison of unitary and multidimensional models of the whiteley index 470 in a nonclinical sample: implications for understanding and assessing health anxiety revision of the padua inventory of obsessive compulsive disorder symptoms: 473 distinctions between worry, obsessions, and compulsions perceived risk, anxiety, and behavioural responses of the general public during the 476 early phase of the influenza a (h1n1) pandemic in the netherlands: results of three consecutive 477 online surveys perceptions and behavioral responses of the general public during the 2009 479 influenza a (h1n1) pandemic: a systematic review the physical activity vital sign: a primary care tool to 482 guide counseling for obesity the audit alcohol consumption questions (audit-c): an effective brief screening 484 test for problem drinking audit-c as a brief screen for alcohol misuse in primary care suicides associated with the 2008-10 economic recession in england: time trend 488 analysis the depression anxiety stress scales (dass): normative data and 490 latent structure in a large non-clinical sample computer therapy for the anxiety and depression disorders is effective, 493 acceptable and practical health care: an updated meta-analysis the covid-19 pandemic: the 'black swan' for mental health care and a turning 496 point for e-health. internet interventions health anxiety in australia: prevalence, comorbidity, 498 disability and service use prevalence of health anxiety problems in medical clinics diagnostic and statistical manual of mental disorders : dsm-5 internet-based cognitive behavioral therapy versus psychoeducation control for 504 illness anxiety disorder and somatic symptom disorder: a randomized controlled trial exposure-based cognitive-behavioural therapy via the internet and as 506 bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled 507 trial characteristics of and important lessons from the coronavirus 509 disease 2019 (covid-19) outbreak in china the impact of community psychological responses on outbreak control for 512 severe acute respiratory syndrome in hong kong do rates of depression vary by level of alcohol misuse in australian general 515 practice? %j australian journal of primary health inconsistencies between alcohol screening results based on audit-c scores 517 and reported drinking on the audit-c questions: prevalence in two us national samples chronic widespread musculoskeletal pain, fatigue, depression and 520 disordered sleep in chronic post-sars syndrome; a case-controlled study key: cord-343559-kjuc3nqa 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-19-related social isolation and their influences on mental health in ghana date: 2020-10-08 journal: community ment health j doi: 10.1007/s10597-020-00722-4 sha: doc_id: 343559 cord_uid: kjuc3nqa this study assessed the behavioral outcomes of coronavirus 2019 (covid-19) 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 621 surveys were analyzed, with a sensitivity analysis utilized to select covariates for the regression model. the average age of participants was about 36 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-19 social distancing measures should be implemented alongside public education for discouraging unhealthy changes in behaviors. coronavirus 2019 (covid-19) is a novel virus that was first detected in wuhan city, china (lewnard and lo 2020; lin et al. 2020) . over a period of < 5 months (between december 2019 and april 2020), the virus grew from being a local epidemic in wuhan to a fear-inspiring global pandemic. as of september 13, 2020, the virus had killed 920,795 out of 28,787,808 people who tested positive for it (johns hopkins university 2020), making it one of the world's deadliest pandemics (lin et al. 2020; pung et al. 2020) . covid-19 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-19 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-19 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 24 months (josefsberg and buckland 2012; anderson et al. 2020) , measures to cut the chains of infection are the only way to contain covid-19 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. 2020; pung et al. 2020) , is the enforcement of social distancing protocols in affected regions. with covid-19, 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-19 in the short-term. this notwithstanding, their socio-economic impacts can be dire (brooks et al. 2020; armitage and nellums 2020) . 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-19 (anderson et al. 2020; lewnard and lo 2020) . other consequences that are significant but seem underreported (lewnard and lo 2020; armitage and nellums 2020) 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 (2009) that a pandemic such as covid-19 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 (1961) , 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-19-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. 2019; armitage and nellums 2020) 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-19 lockdown. with some predicting the outbreak of a similar epidemic in future (lewnard and lo 2020; li and siegrist 2012) and others seeing the possibility of covid-19 spreading for a long time (li and siegrist 2012; pung et al. 2020) , 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-19-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. 2020 ). 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-19. 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. 2020) , 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. 2020; vindegaard and eriksen benros 2020) . our investigation was based on this primary research question: do changes in behaviors due to covid-19 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-19 mandatory lockdown in ghana. the study population was individuals of the general population, preferably those aged 18 years or more, who were socially isolated as they complied with the mandatory lockdown. participants were selected based on four inclusion criteria: (1) currently living in any of the cities facing mandatory lockdown; (2) having acquired at least a basic education instructed in english, the medium in which the survey was administered; (3) being in social isolation owing to the lockdown; and (4) 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 = 32 and n = 4222 to reach credible findings (merolli et al. 2014; balhara and verma 2014; liang et al. 2006) . considering our research approach and the geographical scope of the study setting, we hoped to achieve a sample size between 250 and 700. 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 23 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. q2 and q3) screened for individuals who did not meet the inclusion criteria. questions 4-8 and 13 captured demographic variables and covariates. changes in behaviors were measured with questions 9-12 as well as 14-23. question 24 presented the 9-item mental scale measure. the 'one question per page' design option that comes with the most legible text (regmi et al. 2017) 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, 10 copies of the questionnaire in sealed envelopes were sent through a private courier to individuals aged 24 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 2 days, questionnaires were completed and returned by 8 out of the 10 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 10 different participants (whatsapp = 4; facebook = 5; twitter = 1). 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-19-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-19. the other changes in behaviors were considered because they could be encouraged by social isolation. table 1 shows a summary of all changes in behaviors and their operationalization. as table 1 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 2016; lund et al. 2018) , can confound the primary relationships of interest. mental health was measured with a 9-item standard scale (with descriptive anchors strongly disagree-1; disagree-2; the individual's gross monthly income continuous --somewhat agree-3; agree-4; and strongly agree-5) from lukat et al. (2016) . this tool is a unidimensional scale that produced satisfactory psychometric properties (including a cronbach's α coefficient = 0.93) 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. 2016 ). in the current study, it produced a satisfactory cronbach's α coefficient of 0.82. scores on the mental health measure were generated in harmony with the lukat and colleagues; items were 'parceled' by adding them up. appendix table 5 shows items of the mental health measure used. this study received ethical clearance from an institutional ethics review committee (# 0012020-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. 2014; balhara and verma 2014) , 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 2 weeks (april 4-16, 2020) and was closed on april 16, 2020. its average completion time was about 7 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 25 (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 (2012) . the shapiro-wilk's test was performed to screen for outliers and confirm normality of data of mental health (garson 2012) . this test on the data confirmed normality (p = 0.294) 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 1998; rezai et al. 2008) . in this analysis, univariate regression models were used to estimate crude coefficients (i.e. standardized and unstandardized coefficients and their 95% confidence intervals) indicating the influence of the covariates and changes in behaviors on mental health. covariates with p > 0.25 were removed and those with p ≤ 0.25 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 95% confidence intervals) representing the influences of changes in behavior and each of the remaining covariates on mental health. any covariate that led to a 10% 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 3 ) as a covariate. at this stage, age and income were removed. we achieved a survey completion rate of 100%, which means all participants (n = 643) completed the survey. after applying the inclusion criteria, 22 questionnaires were dropped. of the 621 remaining questionnaires analyzed, 55% (n = 342) were completed by residents of accra, 25% (n = 157) by residents of kumasi; and 20% (n = 122) by residents of tamale. as table 2 indicates, about 35% (n = 215) of participants were female and 65% (n = 406) were male. about 94% of participants (n = 586) had tertiary education, which means that most of the sample had a high education. the age of participants ranged between 18 and 64 years. table 2 shows some dramatic changes in behaviors. that is, 80% of participants lost moderate physical activity time, with over similarly, more than 50% added at least 1 h to their sedentary behavior time. about 64% (n = 397) of participants were exercising during the lockdown, whereas there was no change in the frequency of smoking for 28% (n = 173) of participants who were smokers. the frequency of alcohol intake increased for 3% (n = 19) and did not change for 26% (n = 164) of participants. the frequency of eating decreased for 12% (n = 75) and increased for 42% (n = 262) of participants. about 8% (n = 50) of participants agreed they used substances to protect themselves against covid-19 and faced a higher risk of domestic violence. sexual activity decreased for 20% (n = 125) and increased for 12% (n = 77) of participants. appendix table 6 shows a distribution of average mental health scores across categorical predictors. table 3 shows some significant correlations at p < 0.001 and p < 0.05. for example, mpatl and mental health are negatively correlated (r = − 0.235; p < 0.001; two-tailed). this result connotes that mental health decreases as moderate physical activity time lost increases. table 4 shows regression coefficients resulting from this and other correlation coefficients in table 3 . it can be seen that moderate pa time lost makes a significant influence on mental health (β = − 0.07; t = − 3.28, p < 0.05), 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 = − 0.85; t = − 46.76, p = 0.000). the influence of 'sf-unchanged' is about 2 times lower compared with that of 'sf-non-smokers' (b = − 2.05; t = − 4.97, p = 0.000), 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 2 times lower compared with that of 'ai-increased' (b = − 2.34; t = − 5.76, p = 0.000), 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 0.7 times higher compared with that of 'ai-decreased' (b = 0.695; t = 4.26, p = 0.000), 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-19 had better mental health compared with those who did not (b = 1.55; t = 3.08, p < 0.05). 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 = 2.44; t = 5.75, p = 0.000). the independence-of-errors and multicollinearity assumptions were met based on tolerance ≥ 0.1 (for each predictor) and durbin-watson = 1.65 (for the regression model) in table 4 (garson 2012 ). a major change in behavior resulting from covid-19-related social isolation is a reduction in physical activity and an increase in sedentary behavior time. ellingson et al. (2018) 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 2011; allen et al. 2014; shim et al. 2014; lund et al. 2018 ) 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. 2012; anderson et al. 2020 ), 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-19 (li and siegrist 2012; anderson et al. 2020) , 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 94% 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. 2009; walsh 2011; allen et al. 2014; shim et al. 2014; lund et al. 2018) . coupled with other distressing conditions caused by social distancing during the spread of covid-19, 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-19 is the individual's immunity, behaviors such as smoking that have the tendency of weakening or disabling the immune system (lawrence et al. 2009; lund et al. 2018) 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-19-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 2000; kaplan et al. 2000 ; chiva-blanch and badimon 2020) confirming a positive table 4 the association between mental health, changes in health behaviors, and covariates (n = 621) 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 < 0.001; *p < 0.05 (kaplan et al. 2000; chiva-blanch and badimon 2020) 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-19. 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 2001; fuhrman 2018 ) 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 2001; fuhrman 2018) . 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-19 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-19. 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. 2015; percival 2016) . we would want to reason that the foregoing result was possibly driven by participants' psychological reaction to using substances to protect themselves against covid-19. 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-19. 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 2000; galinsky and waite 2014) , but researchers, from a psychology perspective, have reasoned based on different scenarios that mental health could improve with sexual activity (ganong and larson 2011) . 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 2000; galinsky and waite 2014) . we opine based on this argument that sexual activity would make a positive short-term influence on mental health during covid-19-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 2014) . 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 2012; yap and sim 2011) , 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-19 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-19-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-19-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-19 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 6 . social determinants of mental health how will country-based mitigation measures influence the course of the covid-19 epidemic? the lancet covid-19 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 (2019-ncov): the need to maintain regular physical activity while taking precautions benefits and risks of moderate alcohol consumption on cardiovascular disease: current findings and controversies growing old (p. 227) changes in sedentary time are 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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-19 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-19 on the mental health in the general population the social determinants of mental health: an overview and call to action covid-19 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 # 0012020-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 5 . key: cord-287684-z3l9tsir 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-19 pandemic: a mixed methods survey of uk mental health care staff date: 2020-08-28 journal: soc psychiatry psychiatr epidemiol doi: 10.1007/s00127-020-01927-4 sha: doc_id: 287684 cord_uid: z3l9tsir purpose: the covid-19 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-19 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: 2,180 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-19 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 (10.1007/s00127-020-01927-4) 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 [2] . 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 [3] . 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 [4] , especially in mental health wards and the supported accommodation settings where many people with complex mental health problems live [5] . 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 [6, 7] . 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 [3, 8, 9] and the suggestion has also been recurrently made that it could provide an opportunity for positive service developments [10] [11] [12] . 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-19 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-19/20-18372) , 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 [13] , 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 30 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 17 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-19 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 97 and 277 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 15-30 min to complete. a copy of the survey is available at this web address: https ://opini o.ucl.ac.uk/s?s=67819 . 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 15 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 [14] . 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 [15, 16] . for this, all survey responses were indexed in the coding matrices by a group of 15 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 3 weeks. we summarise key findings here: our accompanying supplementary report gives much more detail. data were collected from 22 april 2020 to 12 may 2020. in total, 3,712 people started the survey (including many who clicked 'start' but provided no or minimal data) and 1,793 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 2,180. there were 15,010 responses to open-ended items, yielding 295,751 words for rapid qualitative content analysis. a large majority of participants worked in the nhs (1,935, 88.9%). approximately a third described themselves as nurses (664, 30.6%), 347 as psychologists (16.0%), 254 as psychiatrists (11.7%), 97 as social workers (4.5%), and 80 as peer support workers (3.7%). over a third identified as a manager or lead clinician in their service (826, 38.0%). over two-thirds worked with working age adults (1,521, 70.0%), 39.2% worked with older adults (853), just under a third worked with people with learning disabilities (648, 29.8%), around a fifth worked with people with drug and alcohol problems (456, 21.0%), and another fifth worked with people with eating disorders (451, 20.7%). participants could report working with multiple service user populations and/or in multiple settings. the majority worked in england (1,814, 83.4%) with around a third of these based in london (639, 35.3%) and a fifth in the north west (328, 18.1%); three-quarters worked in cities or towns with populations greater than 100,000 (1,623, 75.1%). four-fifths were female (1,378, 80.0%) and almost nine-tenths were from white ethnic groups (1,433, 87.0%). full demographic details, including age, caring responsibilities, and covid-19 status, can be found in table 1x 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 1 shows the five work challenges rated highest in each type of setting; tables 2x-6x report this in further detail. in inpatient wards and crisis houses, infection control challenges, related to table 1 top five rated work challenges* for each setting (see tables 2x-6x and 29x-30x 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 29x shows ratings by profession and table 30x 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 (51.5% and 40.6%, respectively) compared to those not in these roles (31.8% and 21.3%, respectively). half of staff in inpatient and residential settings reported that they could not consistently follow the rules set on infection control (303, 50.5%), and just over a third reported that they could not do this in community and other settings (518, 35.2%). table 2 shows the impediments to this most often identified from qualitative content analysis of responses, with more detail in tables 7x-8x. 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 9x ). 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 3 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 10x 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 2 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 7x-8x 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 4 summarises groups frequently identified as of particular concern, and table 11x gives more detail. we also asked staff whether they were seeing people with mental health difficulties that appeared to arise from the pandemic (table 12x) . some described symptoms directly related to covid-19, such as delusional beliefs regarding covid-19 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 5 summarises responses to a question about which sources of help were currently most important to staff in managing the impact of covid-19 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 13x-14x). table 3 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 = 2,180) (see table 10x 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 15x ). 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 4 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 11x 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-19 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 16x ). 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 17x-19x) . almost all staff in community services (1,011, 94.1%) , and a large majority in crisis services (219, 83.0%), 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 (475, 54.5%) reporting use of this technology as their main means of contact with 20% 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 (815, 73.4%) 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 (818, 74.0% 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 39.8% (442) agreed or strongly agreed that they can be a good way of making the initial assessments. responses to open-ended questions ( table 6 , tables 18x-19x) 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 (725, 65.8%) agreed or strongly agreed that use of remote rather tables 17x-19x 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 (67.8%) answered yes when asked whether they wished to retain longer term any changes made during the pandemic. table 20x 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 21x) . 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-19, 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-19 among people subject to the mental health act [17] . 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-19 pandemic. mental health services in the uk were already under pressure prior to the pandemic [18] 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 [13] . more importantly, we designed the questionnaire early in the pandemic when the evidence of differential effects on some ethnic groups was less striking [19] : 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 [20] . 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-19 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 [21] , 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 [22] . 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-19 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/4378/physi cal_restr aint_final _web_versi on.pdf [23] ; https ://weare agend a.org/ wp-conte nt/uploa ds/2017/03/restr aint-foi-resea rch-brief ing-final 1.pdf [24] ), alongside personal experience, make us question whether restraint is ever truly unavoidable. if it places both staff and service users at risk of covid-19 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=67819 . 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-19/20-18372). 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 4.0 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/4.0/. 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-19: change the conversation (2020) mental health in the age of coronavirus: time for change. social psychiatry and psychiatric epidemiology the covid-19 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-19 outbreak physical health pandemic vs mental health 'epidemic': has our mental health been forgotten? mental health today mental health services in lombardy during covid-19 outbreak patients with mental health disorders in the covid-19 epidemic the covid-19 outbreak and psychiatric hospitals in china: managing challenges through mental health service reform remote consultations in the era of covid-19 pandemic: preliminary experience in a regional australian public acute mental health care setting innovation during covid-19: improving addiction treatment access covid-19 mental health policy research unit group (2020) first reports regarding impacts of the covid-19 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-19 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-19 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-347960-vl5zhxyh 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-19 on mental health: study protocol of a multicentric italian population trial date: 2020-06-05 journal: front psychiatry doi: 10.3389/fpsyt.2020.00533 sha: doc_id: 347960 cord_uid: vl5zhxyh the covid-19 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-19 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-19 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 1—covid-19 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-19+ individuals; b) group 2—covid-19+ group, which includes isolated people directly/indirectly exposed to the virus; c) group 3—covid-19 healthcare staff group, which includes firstand second-line healthcare professionals; d) group 4—covid-19 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 shortand 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-19 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-19 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-19 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 1 -covid-19 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-19+ individuals; b) group 2-covid-19+ group, which includes isolated people directly/indirectly exposed to the virus; c) group 3-covid-19 healthcare staff group, which includes firstand second-line healthcare professionals; d) group 4-covid-19 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-19 pandemic represents an unprecedented event in terms of consequences for physical and mental health of individuals and for the society at large (1) (2) (3) (4) . 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 (5) (6) (7) . from a medical and sociological viewpoint, the pandemic caused by covid-19 represents a unique event, since it does not resemble any other previous traumatic event, such as earthquakes or tsunamis (8) . 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-19 pandemic, the "threat" can be everywhere and can be carried by every person next to us (9) (10) (11) . 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 (12) (13) (14) (15) (16) . those studies showed that people experienced fear of falling sick or dying, feelings of helplessness, increased levels of self-blame, fear, and depression (17) (18) (19) (20) . 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 (21, 22) . 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 (23) (24) (25) . qiu et al. (26) found that 35% 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 18 and 30 years or older than 60 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 (24, 27) . after china, italy has been the first country to face the contagion of covid-19 and one of the countries with the highest number of deaths due to this coronavirus (http://www. salute.gov.it/portale/nuovocoronavirus/). on march 8, 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 4. 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 20 years to become more similar to a western model of care, it has to be acknowledged that 20 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-19 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 (28) (29) (30) . the present study has been developed with the aims to: a) evaluate the impact of covid-19 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 2013 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 30 to june 30, 2020 (https://ec.europa.eu/ eusurvey/runner/covidsurvey2020). the survey takes approximately 15-30 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 1-covid-19 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-19+ individuals; b) group 2-covid-19+ group, which includes isolated people directly/indirectly exposed to the virus; c) group 3 -covid-19 healthcare staff group, which includes firstand second-line healthcare professionals; d) group 4-covid-19 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 18 years through a multistep procedure: 1) email invitation to health professionals and their patients; 2) dissemination of the link through social media channels (facebook, twitter, instagram) and the mailing lists of national psychiatric associations; 3) involvement of national associations of stakeholders (e.g., associations of users/carers); 4) 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 -12 items (ghq-12) (31); the depression, anxiety and stress scale -21 items (dass-21) (32); the obsessive-compulsive inventory -revised (oci-r) (33); the insomnia severity index (34) ; the severity-of-acute-stress-symptoms-adult (35); the suicidal ideation attributes scale (sidas) (36); the impact of event scale -6 items (37); the ucla loneliness scale -short version (38) ; the brief cope (39); the post traumatic growth inventory short form (40) ; the connor-davidson resilience scaleshort form (41) ; the multidimensional scale of perceived social support (42); the pattern of care schedule (pcs)-modified version (43); the maslach burnout inventory (only for health professionals) (44) . 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 1 . the primary outcome of the study is the global score at the dass-21. 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 (45) . 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 (46) . furthermore, a significant difference between groups will be identified (covid-19 quarantine group = covid-19 healthcare professional second-line < covid-19+ group = covid-19 healthcare professional first-line group < covid-19 mental health group). in the covid-19 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-19+ 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-19 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-19 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 1) . moreover, the exposure time to covid-19 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 (47) . descriptive statistics will be calculated for the dependent and confounding variables. a bilateral alpha of 0.05 is considered, and error and confidence intervals are calculated at 95%. the analytic plan will include: 1) data cleaning of the online dataset and replacement of missing values; 2) 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; 3) sub-groups analyses based on the level of exposure to the pandemic (i.e., covid-19 quarantine group vs. covid-19+ patients group vs. covid-19 healthcare staff group vs. covid-19 mental health group); 4) calculation of a propensity score, in order to adjust our findings for the likelihood of being exposed to the pandemic and to the quarantine (48, 49) . 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 (48, 49); 5) 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: 0007593/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-19 quarantine group); people who have had a direct or indirect contact with the virus (covid-19+ patients group); those working in health care units as first or second-line staff (covid-19 healthcare staff group); people with mental health problems, independently from the contact with the virus (covid-19 mental health). this choice is due to the evidence that stress and traumas have a different impact on different target groups (7, (50) (51) (52) . in the covid-19-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 (53) . 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. (23) 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 (3) . 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 (53, 54) , as discussed later in this paper. we hypothesized that internet and social media can play a buffering role in the development of psychiatric symptoms (25, 55) . it may be that online contacts and interactions will limit the detrimental effects of social isolation (56) . moreover, internet can represent the ideal setting for providing supportive interventions through tele-mental health applications (57-60). 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-19+ 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 (61) . 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 (62, 63) . the only study conducted in china so far has documented that over 90% of covid+ patients admitted to the hospital reported significant post-traumatic stress symptoms (62, 64, 65) . 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-19 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. (23) 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 (66) (67) (68) (69) . 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-19 mental health group). although the effects of the coronavirus on mental health have not been systematically studied, it is likely that the covid-19 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 (70) . 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 (71) . for many persons with mental disorders, being alone is a heavy burden, far beyond that experienced by many other persons (72) . 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 10,000 participants, but this target has been reached in only 7 days. therefore, we expect to reach more than 20,000 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 (73, 74) . 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 (75, 76) . 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 (46) 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 (77-79), we aim to develop a psychosocial intervention which will include elements of classic psychoeducation, cognitive-behavioral therapy, and motivational intervention (80) (81) (82) (83) (84) . 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 (85, 86) . 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-19 quarantine group, the main focus of the intervention will be the improvement of healthy lifestyle behaviors; for the covid-19+ patients group, the intervention will include a specific focus on post-traumatic symptoms and on the risk of being socially stigmatized; for the covid-19 healthcare staff group, specific sessions will be dedicated to the burn-out syndrome and the management of stressful situations; for the covid-19 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: 0007593/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-19 pandemic on mental health and implications for 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self-management and treatment-related functionality and characteristics of highly rated anxiety apps date: 2020-07-30 journal: int j med inform doi: 10.1016/j.ijmedinf.2020.104243 sha: doc_id: 350000 cord_uid: eqn3kl5p 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 167 anxiety apps were selected (123 android apps and 44 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 51% of the selected apps used various gamification features to motivate users to keep using them, 32% provided social features including chat, communication with others and links to sources of help; 46% offered offline availability; and only 19% 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-19 pandemic. education, and relationships [4, 2] . 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 [5] . other possible factors that can lead to susceptibility include brain chemistry, personality type, exposure to certain mental and/or physical disorders, trauma and stress [6] . the covid-19 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 [7, 8] . the pandemic is also triggering feelings of fear, worry, sadness, and anger [9, 10] . quarantines, self-isolation, fear of the unknown, loss of freedom and other factors are causing psychological issues in people around the world [11, 12] . 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) [2] 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 [13] . people with preexisting anxiety disorders are showing aggravation of their conditions, for example, many people with ocd are developing new fixations on the covid-19 virus and are experiencing compulsive cleaning [9] . due to the covid-19 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 [14] . 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 [15] . the current covid-19 situation is also affecting the mental well-being of health care workers, who are at a high risk of psychological distress [16] , especially those who are experiencing physical symptoms [17] . 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 [18, 19] . 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 [20, 21] , stress [22] , depression [23] and alcohol dependence [24] , 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 [25] . smartphone apps have high rates of acceptance among the general public, and especially in young people [26] due to its cost effectiveness [27] . many studies have reported that apps have shown positive results in the treatment and management of anxiety [28, 29, 30] . this study aims to analyze the functionality and characteristics of highly 5 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 2020 showed that 96.3% of android apps and 90.84% of ios apps were freely available worldwide [31] . a total of 167 apps, 123 android apps, and 44 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 [32] . 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 41,377 apps are available in the google play store, and more than 44,384 apps are available in the app store [33] . 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: • ic1: anxiety related apps in google play store and app store. • ic2: apps that have a free version. • ic3: apps that have 4+ stars rating. ic3 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: • ec1: apps that have less than 5 raters. • ec2: apps that could not be installed. • ec3: apps that crashed and could not be used after installation. apps that match any of the ec were excluded from the selection. ec1 is based on the heuristic guideline by nielsen [34] , which recommends having five evaluators to form an idea about the problems related to usability. the apps' selection process was established as follows: 1. 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. 2. ic were used to identify relevant apps. 3. apps that met one or more of the ec were excluded. the above actions were carried out in march 2020. a final selection of 123 android apps and 44 ios apps was identified after application of ic and ec. fig. 1 presents the selection results. data collection was carried out using the data extraction form presented in table 1 . each app was installed and assessed to explore its functionality features and characteristics. the devices used for the apps' assessment were: oppo a9 (android 9), and ipad 3 (ios 13). 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 167 apps, 123 android apps, and 44 ios apps were identified as both free and highly rated apps. tables a.11, a.12, a.13, a.14, a.15 and a.16 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 (68%) 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 9 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 5): 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. [35] . the free version of the app is used by many developers as an advertisement tool to attract users into purchasing and unlocking more features [35] . free apps with in-app options are becoming the norm in-app markets. in 2013, in-app purchases accounted for more than 70% of ios app revenue in the us and 90% of revenue in asia [36] . the majority of the selected apps (64%) updated their functionality and content in the three first months of 2020. this could be linked to the current covid-19 pandemic situation. on december 31st, 2019 the who china office was informed of a number of pneumonia cases from an unknown cause, that were later linked to the coronavirus [37] , which has now spread to all regions of the world [38] . to limit the spread and risk of the virus, the who advised the public to practice social distancing and to stay home [39] . 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-19 related content. table 2 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 [40] . several studies have presented evidence supporting the use of meditation in anxiety treatments [41, 42, 43] . one study reported that it was beneficial for a group of chinese nursing students 11 j o u r n a l p r e -p r o o f meditation a1, a8, a9, a10, a13, a16, a18-a21, a23, a25, a30, a33-a37, a40, a41, a44, a56, a59, a62, a66, a67, a70, a82, a86, a92, a98, a105, a106, a111, a121, i1, i2, i6-i10, i11, i13, i16, i18, i23, i25, i29, i30, i32, i34, i40, i42 54 breathing exercises a3, a6, a20, a21, a23, a25, a29, a30 a34, a37, a41, , i29 i33 i7 i9 31 games a31, a32, a43, a46, a51, a58, a60, a63, a65, a84, a96, a101, a112, a119, a120, i12, i14, i15, i17, i20-i22, i24, i27, i28, i31, i36-i39, i41, i43, i44 33 assessment tests a117, a12, a33, a34, a48, a66, a69, a70, a72, a78, a79, a88, a91, a103, a113, i19, i7 17 stories a8, a18, a30, a36, a49, a59, a82, a98, a118, i8, i9, i18, i29, i30, i32, i42 16 mindfulness practices a10, a12, a20, a25, a56, a98, a111, a115, i2, i6, i7, i11, i19, i23, i29, i30 16 guided relaxation a22, a23, a33, a34, a40, a42, a54, a103, a111, a115, i13, i16, i8, i9 14 community chats with app users via the app a8, a25, a27, a50, a61, a63, a78, a85, a119, a123,i19 11 yoga and physical exercises a1, a2, a5, a8, a28, a30, a47, a48, a55, a59, a77, a95, a102, a108, a116, a119, i11 17 motivational and inspirational statements a16, a44, a47, a63, a72, a74, a76, a78, a81,i5, i26, i33 12 online therapy and coaching a18, a26, a27, a34, a50, a89, a90, a92 i19, i35 10 recommending activities and tips a42, a64, a66, a100, a102, a108, a113, a120,i19 9 interactive messaging a17, a18, a48, a49 4 in reducing anxiety symptoms and lowering systolic bp [44] . another study reported that it showed improvements in the reduction of anxiety for breast cancer patients [45] . 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 [46] . additionally, meditation has been shown to be effective in managing various types of anxiety such as panic disorder and agoraphobia [41] . 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 [47] . studies have shown that breathing exercises can improve cognition and overall well-being [48] , while also reducing anxiety [48, 49, 50, 51, 52] . breathing exercises can also have a positive impact on psychological distress, quality of sleep [49] , depression [50, 51, 52] , everyday stress, ptsd, and stress-related medical illnesses [50, 53] . breathing exercises are also used to help with asthma, which was the case in a3 and a6. 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 [54] . 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 31 apps as a management method. it has been shown to be an effective tool for the reduction of anxiety, stress, and depression [55, 56] . it has also shown positive results in the prevention of anxiety and stress-induced changes like hr and bp [57] . 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 [58, 59] . 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 41% 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-19 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 [60] . 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 3 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" [61] . mindfulness practices allow practitioners to shift their concentration to their internal experiences occurring in each moment, such as anxiety and mood problems [65, 66] , and improving an individual's internal cognitive, emotional, and physical experience [67] . 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 [68, 69, 70] . 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 [71] . 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 [72, 29] . a study examining available evidence on cbt have yielded positive results and confirmed its effectiveness for anxiety disorders [73] . cbt has also been used in the treatment of some specific anxiety disorders like ptsd [74] and ocd [75] . it has also been proved effective for depression, alcohol and drug use problems, eating disorders, and severe mental illness [71] . cbt and mindfulness-based therapy can also be useful in reducing anxiety during the covid-19 pandemic [76] . hypnosis is a therapeutic technique designed to bring relaxation and focus to the mind [77] . 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 [78] , and another reported on its considerable benefits to terminally ill patients [79] . hypnosis is also used to treat and manage stress and phobias [80] , as well as sleep and physical symptoms [78] . other approaches have also been identified in the selected apps as shown in table 3 , but it should be noted that a few of them were not based on scientific approaches. table 4 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 a6, a11, a20, a29, a38, a86, a112, i1, i13, i18 10 self-esteem and confidence a18, a20, a21, a83, a88, a118, a121, i1, i2, i5, i18, i26 12 pain a12, a13, a37, a49, a64, a83, a107, i18, i23 9 mood a5, a14, a18, a39, a69, a77, a89, a95, a120 9 some apps addressed other mental and physical issues, which usually occur with anxiety like stress [80, 53] , sleep issues [78] , and depression [71, 41, 53] . some apps used management methods to treat addiction-related issues, eating disorders [71] , phobias, [80] , and asthma [54] . the majority of the apps do not use physical health information. hr and bp are impacted by anxiety and stress [57] . both can be used by apps to indicate the anxiety level of the user [20] . yet in our selection only two apps provided this functionality feature (a6 and a113). a113 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 a6 provides cardiovascular tests, including hr and peripheral blood circulation, as an app purchase option. only 19% of the selected apps reported involvement of mental health care professionals as presented in table 5 . 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 5 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 5 and found them to be legitimate. table 5 table 6 presents the authentication methods identified in the selected apps. the majority of the selected apps (66%) 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 a97 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 a97 1 gamification is the use of game elements in non-gaming systems which are mainly used to improve user experience and user engagement [81] . table 7 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 [82, 83] , and aggression for veterans [84] . combining j o u r n a l p r e -p r o o f game a31, a32, a43, a46, a51, a58, a60, a63, a65, a72, a84, a96, a101, a112, a119, a120, i14, i15, i17, i20-i22, i24, i27, i28, i31, i36-i39, i41, i43, i44 33 graphics a3, a6, a29, a30, a37, a41, a55, a59, a70, a73, a76, a80, a83 unlocking new features a114, a17, i18, i33, i7 5 score and points a27, a48, a54, i8 4 stickers, awards and stars a14, a16, a20, a100, i11 5 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 8 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 [85] . it has a favorable effect on certain psychological issues [86] , and can serve as a mediator to stress and anxiety caused by life events [87] . providing social support is also among the behavioral change techniques implemented in m-health apps to promote app usage [88] . additionally, providing contacts in case of emergencies is crucial and might help the user in critical situations 23 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 a12, a120, a34, a40, a54, a61, a63, a76, a91 9 group treatment i34, i35 2 table 9 presents the languages available in the selected apps. the majority of the apps (127 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 (a98) 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. i2, i4-i7, i9, i10, i11, i13, i14, i16, i21, i23-i26, i29-i35, i37, i38, i40-i44 129 more than one language a1, a2, a6, a8, a10, a14-a16, a30, a34, a37, a44, a46, a58-a60, a62, a85, a88, a89, a101, a113, a120, i1, i3, i8, i12, i15, i17-i19, i20, i22, i27, i28, i36, i39 37 system's languages a98 1 j o u r n a l p r e -p r o o f table 10 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-19 pandemic, the use of mobile communication and apps for anxiety might become a necessity. panic attacks can mimic covid-19 symptoms, which might worsen the condition of people with anxiety disorders [89] . 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 25020 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 [90] , 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-19 pandemic, mhealth can also help disseminate health information among health personnel and community workers [91] . 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, statistij 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: -167 free and high-rated anxiety apps were analysed: 123 android apps, and 44 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 anxiety everything you need to know about anxiety share of the population worldwide who suffered from anxiety disorders from what are anxiety disorders? anxiety causes immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the 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cognitive-behavioral therapy for ocd mental health strategies to combat the psychological impact of coronavirus disease 2019 (covid-19) beyond paranoia and panic hypnosis and relaxation therapies a hypnotherapy intervention for the treatment of anxiety in patients with cancer receiving palliative care use of hypnotherapy in anxiety management in the terminally ill: a preliminary study the clinical use of hypnosis in cognitive behavior therapy: a practitioner's casebook gamification. using game-design elements in non-gaming contexts a virtual reality exposure therapy application for iraq war military personnel with post traumatic stress disorder: from training to toy to treatment cognitive processing therapy for veterans with 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-19. 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-19 epidemic response deep key: cord-252161-1ve7heyb authors: maulik, pallab k.; thornicroft, graham; saxena, shekhar title: roadmap to strengthen global mental health systems to tackle the impact of the covid-19 pandemic date: 2020-07-29 journal: int j ment health syst doi: 10.1186/s13033-020-00393-4 sha: doc_id: 252161 cord_uid: 1ve7heyb 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 covid19. 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 2 of 13 maulik et al. int j ment health syst (2020) 14:57 community structures across the globe is potentiating a major international mental health crisis [1] [2] [3] [4] . the mental health impacts of covid-19 can be varied and severe and have been outlined recently [5] . 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 [6] . 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 19 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 [5] . 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 [7, 8] . researchers have highlighted the need for focussed research that should be funded related to the impact of covid-19 [9] . most mental health systems across the world have been woefully inadequately funded, planned, organised and delivered given the major global burden of mental disorders [10] . the codid-19 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 [11] , 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 2013-2020 [12] and the who health systems strengthening framework [13] , 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" [14] . table 1 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 2 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 3 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 19 pandemic and any similar challenges in future, should be tackled along the lines of a humanitarian emergency [15] . even during more normal times, addressing mental health needs as part of the sustainable development goals has been a major challenge [6] . 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 [2] . not only will covid 19 lead to a surge in mental health needs in the community [5, 7] , 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 [5] . 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 1, 2 and 3 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 [15] , 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 [16] . 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 [12] . 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 [12] , 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 [11, 17] . 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 [18, 19] . 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 [20] . 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 [21] . 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 [22] 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 19 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 2030 is already underway [23] . 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 [9, 24, 25] . 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 [26] . 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-19 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 19 following the principle of building back better [14] 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 [27] , and to make mental health an integral part of the management of covid 19 [28] . covid-19 exposes the cracks in our already fragile mental health system policy brief: covid 19 and the need for action on mental heath mental health and covid-19: change the conversation addressing mental health needs: an integral part of covid-19 response mental health of communities during the covid-19 pandemic the lancet commission on global mental health and sustainable development posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid-19 pandemic multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science world health organization. mental health atlas global preparedness against covid-19: we must leverage the power of digital health world health organization. mental health action plan 2013-20. 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-19 crisis rapid implementation of mobile technology for real-time epidemiology of covid-19 mental health services in italy during the covid-19 outbreak mental health services in lombardy during covid-19 outbreak challenges and recommendations for mental health providers during the covid-19 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 2030 challenges and burden of the coronavirus 2019 (covid-19) 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-19, 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-19. 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-19 publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations received: 19 june 2020 accepted: 23 july 2020 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-274996-fk510s1v 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: 2020-10-02 journal: int j ment health syst doi: 10.1186/s13033-020-00406-2 sha: doc_id: 274996 cord_uid: fk510s1v 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 60 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 2 of 12 babatunde et al. int j ment health syst (2020) 14:73 policy documents have helped to spur this [49] [50] [51] , notably the world health organization's (who) policy framework for child and adolescent mental health policies and plans [49] . 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 [25] . the burden of camh has been well-described, especially in lmics [17, 37] . barriers to camh service provision in lmics will undoubtedly be aggravated by the covid-19 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 [19] . 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 [25, 30, 35, 47] . notably, the mental health gap project (mhgap) [51] 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 [10, 11] . 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 [27, 33] . 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 [26] . haine-schlagel et al. [22] , 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 [14] and the national mental health policy framework and strategic plan 2013-2020 [16] , 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 [46] . the framework consists of ten elements, they include, (1) goals and outcomes, (2) values and principles, (3) service delivery, (4) the population, (5) the context, (6) leadership and governance, (7) finances, (8) human resources, (9) infrastructure and supplies, (10) 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 [46] . 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 [42] 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 [38] . 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 6911 km 2 with a population estimate of about 442,266, is made up of 3 sub-districts and comprises rural and periurban communities [1, 20] . 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 [20] . 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 [15] . 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 [3, 31] . 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 60 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 12 months have been published elsewhere [6] . 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 1 and 2 . data gathering for this study took place from february to march 2019. 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 [4, 13] . 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 [5] 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 [18] framework method, a summary process for managing and analysing qualitative data, which produces a series of themed matrices [44] . accordingly, six steps were followed: (1) transcription, (2) familiarisation, (3) deductive organisation of codes based on the elements of the hsd framework, (4) inductive coding of sub-themes under the hsd coding framework, (5) reviewing data extract and charting (6) mapping and interpretation of data [18, 40] . 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 [8, 48] . the categories were reviewed to identify existing connections and differences between the themes from the different groups of stakeholders [45] . the excel software package (2019) 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 4). 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 1). 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 1). 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 1) . 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 1). 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 2). 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 2 pm, so that at least they will be able to go to school in the morning. " (psychologist 1). 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 1). 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 150, but due to the increasing number of children with mental disabilities we have about 350 leaners, our school is full. " (educator 2, special school 1). 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 7). 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 13). 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 10 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 18 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 18. " (caregiver 17). 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 14) . 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 11). 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 1). 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 4). 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 2). 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 14). 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 [23] 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 [7] , 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. [32] 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 [36] , 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. [9] , 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 [27, 33, 43] 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. [41] 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 [2, 12, 21, 28, 34, 39] 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 [24] 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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action programme: scaling 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 (201446). 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 be098/18). 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-319051-naj1nl9x 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-2 date: 2020-04-17 journal: rev psiquiatr salud ment doi: 10.1016/j.rpsm.2020.04.002 sha: doc_id: 319051 cord_uid: naj1nl9x 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 1,2 . la reciente aparición y rápida propagación en wuhan (china) del nuevo coronavirus sars-cov-2 supuso la toma de medidas sin precedentes como el cierre de wuhan y la cuarentena de millones de habitantes en provincias y localidades adicionales 3 . 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 4 . 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 5,6 . a finales de 2019 se reportaron en wuhan los primeros casos de una neumonía de causa desconocida. pronto se identificó el coronavirus sars-cov-2 como agente causal de la enfermedad covid-19. generalmente cursa con fiebre, tos y disnea, presentando una tasa de mortalidad de aproximadamente el 2% 7, 8 . el 30 de enero de 2020 la oms declaró covid-19 como epidemia y pheic (public health emergency of international concern). el 11 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 9 . en la epidemia de sars de 2003, 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 10 . entre el personal de urgencias en taiwán, el 19.3% presentó sintomatología significativa de síndrome de estrés postraumático 11 . en la epidemia de mers de 2015 de corea del sur se vio que entre los pacientes aislados predominaban síntomas de ansiedad e ira, especialmente en pacientes con antecedentes psiquiátricos 1 . estas epidemias, causadas por otros coronavirus, pueden ofrecer pistas sobre los posibles efectos sobre la salud mental de covid-19 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 16.5% y un 28.8% refirieron respectivamente síntomas depresivos y de ansiedad de intensidad moderada-grave 3 . se ha señalado que entre los sujetos que padecen una enfermedad mental el impacto podría ser todavía mayor 12, 13 . en cuanto a los pacientes diagnosticados de covid-19, 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 9 . 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 14, 15 . un estudio en china encontró entre ellos una alta prevalencia de síntomas de depresión, ansiedad e insomnio (50,4%, 44,6% y 34,0%, respectivamente). las mujeres, enfermería, y los trabajadores más expuestos reportaron más síntomas 14 . en conjunto, estos datos despiertan preocupación sobre el bienestar psicológico del personal sanitario implicado. la pandemia por covid-19 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/h1n1 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 16 . 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 9,17,18 . 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-2 es necesario continuar con la implementación y el desarrollo de servicios de salud mental en la respuesta sanitaria ante covid-19. 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 2019 coronavirus disease (covid-19) epidemic among the general population in china the mental health of medical workers in wuhan, china dealing with the 2019 novel coronavirus mental health care measures in response to the 2019 novel coronavirus outbreak in korea public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations review of the clinical characteristics of coronavirus disease 2019 (covid-19) epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. the lancet psychiatry 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-19 epidemic. the lancet psychiatry 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 psychological crisis interventions in sichuan province during the 2019 novel coronavirus outbreak a novel approach of consultation on 2019 novel coronavirus (covid-19)-related psychological and mental problems: structured letter therapy mental health care measures in response to the 2019 novel coronavirus outbreak in korea public responses to the novel 2019 coronavirus (2019-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-344584-t421g3zc authors: swendsen, joel title: covid-19 and mental health: how one pandemic can reveal another date: 2020-09-15 journal: j behav cogn ther doi: 10.1016/j.jbct.2020.08.001 sha: doc_id: 344584 cord_uid: t421g3zc the covid-19 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-19 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-19 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., 2013) . 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., 2007; kessler et al., 1997; kessler et al., 1994; merikangas et al., 2010; regier et al., 1990) . 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 2 to 4 hours. interviews are shorter (2 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 50% 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 9.6% 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, 2018). 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., 2016) . 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-19 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 24th, 2020, covid-19 had caused 800,000 deaths worldwide (world health organization, 2020a) . this is precisely the same number of people who commit suicide every year (world health organization, 2020b). the difference is that covid-19 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-19 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 12-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 2018: 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-321749-mf821b1p authors: buckley, ralf; westaway, diane title: mental health rescue effects of women's outdoor tourism: a role in covid-19 recovery date: 2020-10-20 journal: ann tour res doi: 10.1016/j.annals.2020.103041 sha: doc_id: 321749 cord_uid: mf821b1p mental and social health outcomes from a portfolio of women's outdoor tourism products, with ~100,000 clients, are analysed using a catalysed netnography of >1000 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-19 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, 2019; patel et al., 2018) . these costs amounted to ~10% of global gnp prior to the 2019/20 covid-19 coronavirus pandemic. they are increasing currently through covid-19 lockdown, isolation and quarantine measures (brooks et al., 2020) . 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., 2019; frumkin et al., 2017) . these confer an additional economic value on national parks, estimated at > us$6 trillion p.a. worldwide . this health services value is generated via outdoor nature and adventure tourism and recreation (buckley, 2019 (buckley, , 2020 . it is at least ten times larger than the direct economic value of tourism in parks (balmford et al., 2015) . 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 7.5% . these additional costs are indeed now being incurred, as one component of the social and economic costs of covid-19 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-19 family confinement (brooks et al., 2020) . irrespective of the current covid-19 pandemic, women worldwide are disproportionately susceptible to many of the causes of poor mental health (halliday, kern, & turnbull, 2019; hodes & epperson, 2019) . this occurs through: domestic violence and table 1 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 85 (2020) 103041 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., 2019; uysal, sirgy, woo, & kim, 2016) . this is a heavily studied field, with several recent reviews (pyke, hartwell, blake, & hemingway, 2016; smith & diekmann, 2017; uysal et al., 2016) . there is also a parallel but more prescriptive field known as positive psychology (coghlan, 2015; filep & laing, 2019; nawijn & filep, 2016; vada et al., 2020) . 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, 2017; chen & li, 2018; gabor & oltean, 2019; pyke et al., 2016) ; and on medical tourism (hoz-correa, munoz-leiva, & bakucz, 2018; mathijsen, 2019) . 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, 2017) , and improve quality of life (iwasaki, 2017; wensley & slade, 2012) , through preventive and therapeutic pathways (fenton et al., 2017; l. fenton, white, gallant, hutchinson, & hamilton-hinch, 2016; l. fenton, white, hamilton-hinch, & gilbert, 2018; y. iwasaki et al., 2014; y. iwasaki, coyle, & shank, 2010) . non-commercialised outdoor recreation, including exposure to nature, can yield a wide range of health benefits, both physiological and psychological (biedenweg, scott, & scott, 2017; bratman et al., 2019; davies, 2018; kondo, jacoby, & south, 2018; twohig-bennett & jones, 2018) . those benefits include reduced incidence of medically diagnosed syndromes, such as clinical depression and alzheimer's and parkinson's diseases (hansson et al., 2019; svensson et al., 2019; tomas, martina, ulf, stefan, & tomas, 2019) . critically, they include marginal gains beyond those of exercise alone (araújo, brymer, brito, withagen, & davids, 2019; bélanger et al., 2019; blondell, hammersley-mather, & veerman, 2014; chekroud et al., 2018; clough, mackenzie, mallabon, & brymer, 2016; elbe, lyhne, madsen, & krustrup, 2019; frühauf et al., 2016; horowitz et al., 2020; niedermeier, einwanger, hartl, & kopp, 2017; pasanen, white, wheeler, garrett, & elliott, 2019; white et al., 2016) . mental health benefits have been shown for many different types of adventurous outdoor recreation (araújo et al., 2019; buckley, 2018a; collins & brymer, 2018; frühauf et al., 2016; hansson et al., 2019; hetland, kjelstrup, mittner, & vitterso, 2019; holland, powell, thomsen, & monz, 2018; holmbom, brymer, & schweitzer, 2017; morris & scott, 2019; niedermeier et al., 2017; roberts, jones, & brooks, 2018; white et al., 2016) . benefits have also been demonstrated for contemplative outdoor activities, such as forest walks (chen, yu, & lee, 2018; hansen, jones, & tocchini, 2017; kobayashi et al., 2018; lyu et al., 2018; morita et al., 2007; oh et al., 2017) . there is a parallel field of geographical research on therapeutic landscapes (bell, foley, houghton, maddrell, & williams, 2018) . 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., 2018) . mental health benefits from activities in outdoor nature have been summarised in several recent reviews and meta-analyses (bratman et al., 2019; buckley & brough, 2017a; frumkin et al., 2017; kondo et al., 2018; oh et al., 2017; seymour, 2016; shanahan et al., 2016) . benefits can occur across a wide range of mental health parameters, environments (biedenweg et al., 2017; wyles et al., 2017) , 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., 2019; patel et al., 2018) . 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, 2017b; buckley, brough, & westaway, 2018; van den berg, 2017) . 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., 2019; buckley, brough, 2017b; frumkin et al., 2017; shanahan et al., 2016) , though research has begun . prescriptible therapies need institutional systems for diagnosis, prescription, certified providers, and funding (buckley et al., 2018) . commercial outdoor tourism can capitalise on this by repackaging tourism products as therapies (buckley, 2019) . maintaining and improving mental health is valuable both socially and economically. many people are mentally languishing rather than flourishing (keyes, 2002 of the population each year experience common mental health disorders (australia institute of health and welfare, 2018) . treatment by prescribing opioid antidepressants has created very large secondary social costs through addiction (johnson, eriator, & rodenmeyer, 2018; kolodny et al., 2015; kolodny & frieden, 2017; murthy, 2016) . 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-19 pandemic, at ~10% of gdp (buckley, brough, 2017a , 2017b australia, productivity commission, 2019) . costs include treatments, carers, lost workplace productivity, and antisocial behaviours (buckley et al., 2018) . in the longer term, costs are growing, because of increasing individual longevity, workplace stress, and childhood videophilia (cooper, 2018; pergams & zaradic, 2008; soga & gaston, 2016; zhang, goodale, & chen, 2014) . as children spend less time outdoors, this creates health costs that persist throughout adulthood (engemann et al., 2019; lee et al., 2017; stafford et al., 2015) . 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-19 lockdowns are increasing these costs worldwide (liu, bao, huang, shi, & lu, 2020; mazza et al., 2020; pierce et al., 2020; vizard, davis, white, & beynon, 2020; wang et al., 2020) . 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., 2002; pohl, borrie, & patterson, 2000) , across the entire life course (carmichael, duberley, & szmigin, 2015; cosgriff, little, & wilson, 2009; wharton, 2018) . women may have different motivations and learning styles than men (kiewa, 1994; whittington, 2006) ; face different barriers and encouragements to take part in various outdoor activities (doran, schofield, & low, 2018; little, 2002; loeffler, 1997; mcniel, harris, & fondren, 2012; morris, van riper, kyle, wallen, & absher, 2018) ; and attach importance to different aspects and achievements (kiewa, 2001; nolan & priest, 1993) . there is also a small and recent research literature on family adventure tourism, where parents and children take part jointly (pomfret, 2018; g. pomfret & varley, 2019) . regular walking groups and programs as a form of low-key therapy, especially for women, have received particular attention recently (davies, 2018; duncan, gordon, & scott, 1991; hanson & jones, 2015; kelly et al., 2018; legrand & mille, 2009; marselle, warber, & irvine, 2019; robertson, robertson, jepson, & maxwell, 2012) . simply encouraging people to walk regularly, however, is ineffective (hillsdon, thorogood, white, & foster, 2002; ogilvie, foster, & rothnie, 2007) . a suite of social levers is required to achieve high take-up and repeat activity (buckley et al., 2018) . 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, 2015; halliday et al., 2019; hodes & epperson, 2019; kessler, 2003; lemoult & gotlib, 2019; salk, hyde, & abramson, 2017) . 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 (2019) 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 (2018) conducted repeated clinical interviews, using a psychiatric rating scale, with 14 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 (2020) conducted brief interviews with 238 tourists visiting forest and beach parks in australia, and found that 82% 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, 2018; ower et al., 2018) . 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, 2013) , run in various australian states (buckley et al., 2016; westaway, 2018) . the company has ~100,000 clients to date, about 1% 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 3 products each have entirely or largely female clientele. the methodology adopted is internet-based ethnography, known as netnography (kozinets, 2002 (kozinets, , 2015 . 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, 2018; mkono & markwell, 2014; tavakoli & mura, 2018; veal, 2017) . 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 1000 individual posts had been examined, posted by several hundred different individuals, all female. many posts were responses to a video presentation (westaway, 2018) . we excluded posts referring only to physical fitness, and very brief posts with limited conceptual content. for the catalysed netnography, we used a 4000-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, 2017; stern & porr, 2017) . concepts were extracted, coded, and classified iteratively, to build a coding tree (buckley, 2018b; glaser & strauss, 2017; stern & porr, 2017) . coding was checked by two independent analysts. iterations were repeated until theoretical saturation and efficient coding were achieved (aldiabat & navenec, 2018; buckley, 2018b; denovan & macaskill, 2017; nelson, 2017; saunders et al., 2018) . 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 2 . 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 2 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 58 basic themes, classified into 10 psychological constructs and 5 social constructs (table 2) . we presented the psychological constructs in 4 groups: happiness and gratitude; relaxation, release, and clarity; capability, transformation, and missing life components; and psychological rescue. we presented the social constructs in 3 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, 2019) . 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, 2020) . 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-19 pandemic during 2020 has created major social, economic and environmental changes, the "anthropause" (rutz et al., 2020) , 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., 2020; liu et al., 2020; mazza et al., 2020; mucci, mucci, & diolaiuti, 2020; pierce et al., 2020; vizard et al., 2020; wang et al., 2020) . 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, 2019) . 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, 2019 (buckley, , 2020 buckley, zhong, & martin, 2020) . this paradigm argues that for the us$600 billion p.a. parks and nature tourism sector (balmford et al., 2015) , mental health is an integral consideration across the entire sector. our findings here, from a commercial outdoor tourism clientele now representing 1% 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, 2020) . 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., 2019; smith & diekmann, 2017; vada et al., 2020) . 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, 2020; xie & fan, 2017) . 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, 2019; lee, bullock, & hoy, 2016; mueser et al., 2007; swan, keen, reynolds, & onwumere, 2017) . the concept of emotional rescue is well established within popular culture (richards & jagger, 1980) , but using tourism to achieve it is a new addition to social practices (buckley et al., 2016) . 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, 2018; steptoe & fancourt, 2019) . 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, 1951; flouri & buchanan, 2003; lavenda & kestler-peleg, 2018; luebbe & bell, 2014; repetti, taylor, & seeman, 2002) , and that these may persist lifelong (fingerman, huo, graham, kim, & birditt, 2017; lee et al., 2017; mallers, charles, neupert, & almeida, 2010; stafford et al., 2015) . 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, 2018; buckley, 2018a; collins & brymer, 2018; holmbom et al., 2017; houge mackenzie & brymer, 2018; morris & scott, 2019; roberts et al., 2018; zanon, curtis, lockstone-binney, & hall, 2018) . other outcomes identified here, such as happiness, relaxation and destressing, challenge, and companionship, have been reported in previous qualitative studies of hiking (davies, 2018; kelly et al., 2018; lyu et al., 2018; richardson & mcewan, 2018; wensley & slade, 2012) . 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., 2017; bratman et al., 2019; buckley, brough, 2017a , 2017b clough et al., 2016; frühauf et al., 2016; frumkin et al., 2017; niedermeier et al., 2017; oh et al., 2017; seymour, 2016; shanahan et al., 2016; wang et al., 2017; white et al., 2016 white et al., , 2019 wyles et al., 2017) . 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., 2019; patel et al., 2018) . 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., 2016) . 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-19 pandemic (liu et al., 2020; mazza et al., 2020; mucci et al., 2020; pierce et al., 2020; vizard et al., 2020; wang et al., 2020) ; 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., 2020; graham-harrison, giuffrida, smith, & ford, 2020 ). 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 other demographic and socioeconomic sectors, and other countries and cultures. practical adoption appears to have leapfrogged research. in the us and uk, government healthcare 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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 #2017/838. key: cord-310121-npt8i9bc authors: poole, norman a. title: if not now, when? date: 2020-03-27 journal: bjpsych bulletin doi: 10.1192/bjb.2020.37 sha: doc_id: 310121 cord_uid: npt8i9bc the editor of the bjpsych bulletin reflects on the extraordinary recent events triggered by the covid-19 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 3-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. 1 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-19 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 200 years ago to prevent contagion seeping out into the community at large. 2 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-19 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. 3 tomlin's editorial 4 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. 5 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 6 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. 7, 8 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. 9 unlike post-2008, 10 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-70s. 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? 11 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-20 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 26284) crashed: how a decade of financial crises changed the world if not now, when? penguin modern classics none. key: cord-296422-5lsyh6s5 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 lowand middle-income countries through a task-shifting approach date: 2020-08-03 journal: epidemiol psychiatr sci doi: 10.1017/s204579602000061x sha: doc_id: 296422 cord_uid: 5lsyh6s5 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-cov2 virus may have neurological/ neuropsychiatric impact on the brain (holmes et al., 2020) . 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 30 causes of years lived with disability. the highest contributors are anxiety and depressive disorders, drug-use disorders and alcohol-use disorders (dalys and collaborators, 2018) . mental health and behavioural disorders contribute 7.4% of the global burden of disease in the world, more than, for example, tuberculosis (2.0%), hiv/aids (3.3%) or malaria (4.6%) (whiteford et al., 2013) . the contribution of major depressive disorders to worldwide disability-adjusted life years has increased by 37% from 1990 to 2010 and is predicted to rise further (prince et al., 2007; murray et al., 2012) . 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, 2010 , 2015 . 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., 2018) . 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., 2015) . 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 1 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., 2018) . 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, 2019; barbui et al., 2020 ). the gap between the individuals in need of mental health interventions and those who actually receive such care remains very large (world health organization, 2015) . a study of 21 countries with the who mental health surveys found that 52.6% of persons with depressive disorder in lmics received any treatment in the past 12 months, and only 20.5% of persons with depressive disorder received minimally adequate treatment (thornicroft et al., 2017) . 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., 2012) . this is despite the existence of a range of cost-effective interventions in mental health care in lmics (tol et al., 2011; van ginneken et al., 2013; purgato et al., 2018a purgato et al., , 2018b barbui et al., 2020) . 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., 2019) . 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., 2018) . 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, 2015) . 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., 2003; chatterjee et al., 2003; chatterjee et al., 2008) . 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, 2001; gordon et al., 2008; shen et al., 2018) and for the delivery of prevention interventions (ager et al., 2011) . 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., 2013update in progress) , though still only a small percentage of psychological interventions in lmics actually include nonspecialists as providers (fig. 2) . 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, 2009). 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, 2012; tol et al., 2015) . prevention is further subdivided on the basis of the population targeted, into universal, selective and indicated (national research council and institute of medicine, 2009). 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, 2007) 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, 2011); 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, 2009), 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., 2011) . 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., 2019a) , 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., 2015) . this includes facilitator-guided self-help group interventions, as for example the who self-help plus (epping-jordan et al., 2016; purgato et al., 2019a) . 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., 2011; baingana et al., 2015) . 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 2018 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., 2018) . 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., 2013) . 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., 2018) . 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., 2013; barbui et al., 2020) . 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., 2018) . 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., 2018) . 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., 2018) . 'for an instance, it is a very common myth that people suffering from mental illness rarely get recovered in south western nigeria' (orngu, 2015) . 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., 2017) . 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., 2017; wainberg et al., 2017) . furthermore, low levels of knowledge regarding mental health problems have been suggested as an important factor that delays the interventions' onset (henderson et al., 2013) . 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., 2011) and limited dissemination and implementation research capacity (wainberg et al., 2017) . 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., 2018) . 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, 2008; yasamy et al., 2011) . 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., 2011) . 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., 2017) . 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., 2017) . 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., 2013update 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., 2019b) . 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, 2016; cuijpers et al., 2018) , 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 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mental, neurological and substance-abuse disorders in low-and middle-income 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 (2011) psychological first aid: guide for field workers responsible governance for mental health research in low resource countries key: cord-338033-pl5hyzwp authors: carbone, stephen r. title: flattening the mental ill-health curve: the importance of primary prevention in managing the mental health impacts of covid19 date: 2020-05-15 journal: ment health prev doi: 10.1016/j.mhp.2020.200185 sha: doc_id: 338033 cord_uid: pl5hyzwp the covid19 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 covid19 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 covid19, 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 covid19 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 covid19 title flattening the mental ill-health curve: the importance of primary prevention in managing the mental health impacts of covid19 author names and affiliations. the coronavirus disease 2019 (covid19) 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-2 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 reacti