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The impact of COVID-19 pandemic and the constraints it has imposed on people is an issue of interest and concern to patients, service users, carers and health and social care professionals alike. In pandemic conditions it is likely that people’s existing mental health problems may get worse. Mental health may also decline because of social isolation, loss of employment, stress and health anxiety caused by the pandemic and the steps taken to control it.

This Collection brings together NIHR research on several aspects of mental health that are particularly relevant to the COVID-19 situation. We asked a number of health and social care professionals and service users to comment on selected Alerts that are relevant and important to them. Their commentary highlights what we can learn from the research summarised in the Alerts to better understand and treat mental health problems during COVID-19 and its aftermath.

The Alerts included in this Collection are:

Social prescribing could empower patients to address non-medical problems in their lives

Read the Alert on social prescribing

Dr. Rebecca Chubb, Locum Consultant Psychiatrist 

“The crippling nature of loneliness has been more prevalent during the [COVID-19] pandemic than ever before. Anything which can help maintain a person’s confidence and motivation is a welcome thing, not only for primary care but also for secondary mental health services where loneliness can be the precipitator for an episode of depression.

“The huge benefit for me of social prescribers is their local knowledge. So often, small scale groups do not have fancy websites or money for publicity so having somebody with ‘the knowledge’ akin to London taxi drivers but of support, people, groups and interventions is invaluable.”

Dr. Godfred Boahen, Social Worker

“This research shows that link workers can be important in how social workers manage the needs of people who have mental health needs but do not meet the threshold for statutory social services from escalating. At the point of referrals social workers/ social care workers can signpost people to link workers within GP surgeries.”

Sarah Bodell, Occupational Therapist 

“There is clearly great synergy between occupational therapy and social prescribing. However, to maximise the potential of both roles requires close working. Both professions need to understand each other’s roles, the similarities and differences, know when and how to refer to each other and to develop pathways that facilitate joint working. There is also the potential for occupational therapists to provide education and supervision to social prescribers, who currently are drawn from a range of backgrounds and who do not currently have a core competency framework.”

Guided online interventions can help people recover from depression

Read the Alert on online interventions

Debs Smith, Patient and Public Involvement (PPI) volunteer with lived experience of mental health

“This Alert goes along with my experience of accessing online support. I agree that a stepped approach is necessary and online resources don’t work for everyone: it works for some people and it works well for those if they are given support to work through the resources. The fact it works for some people may free up face to face support for those who need it most.

“We need to consider those who don’t have access to online resources either because of cost or not wanting or knowing how to use them. I think this is very relevant for COVID-19: I could have done with this support during the lockdown when my depression and anxiety got worse and I had no services I could turn to.”

Jane Boland, Occupational Therapist 

“I work for a charity which provides 1:1 therapy for men in a suicidal crisis who are often experiencing symptoms of depression or being treated medically via primary care. During COVID-19, we moved to deliver our therapy via video or phone calls using a structured method with supporting tools such as handouts, diaries and cards.

“As an organisation, we are keen to explore how we could expand the reach of our innovative intervention and whether a guided/virtual therapy would be safe and effective. This research indicates that this may be an area of future development and is useful to support organisations that are looking at how therapy can be delivered to large populations safely and effectively. It looks to supplement an online experience with the provision of an expert helper and that has merit. I would worry about the large number of people who would be excluded from this approach – people without access to the requisite technology and people who can’t read.”

Combined drug and psychological therapies may be most effective for depression

Read the Alert on combined drug and psychological therapies

Danielle Adams, Independent Specialist Mental Health Pharmacist

“This paper highlights the need for a joined up multidisciplinary approach to healthcare interventions in order to deliver best practice in the treatment of depression, offering evidence-based treatments to patients within the shared decision-making framework.

“It is interesting to note that the combined pharmacological and psychotherapy was found to be more acceptable to patients than using medicines alone. Many of the adverse effects experienced by patients when SSRIs are initiated are self limiting e.g. increased symptoms of anxiety and by combining with psychotherapy may provide an enhanced treatment plan which may be more acceptable.

"Although none of the papers in this study involved guided self-help or internet-based therapies, these types of psychological interventions can provide the opportunity for the findings in this paper to be more readily implemented within routine clinical practice. Enabling GPs to provide patients with the treatment option of combination therapy will give patients improved evidence-based treatment options, reduce delays in referrals to secondary providers and and give access to treatment which it is hoped will improve health outcomes. This is especially important during the current COVID-19 pandemic when some people are shielding and in quarantine, and health providers are reducing face to face contact. However, the combination of medicines and psychotherapy does not replace the need for monitoring and reviewing treatment at appropriate time intervals in order to optimise interventions, maximising effectiveness and maintaining patient safety, reducing the risks of adverse effects. Further opportunities in primary care for providing information and discussions about treating depression in this way can be provided by other members of the healthcare team such as practice nurses and pharmacists.”

Ambulance staff who respond to suicides need more support

Read the Alert on support for ambulance staff

Nigel ReesHead of Research and Innovation for the Welsh Ambulance Services NHS Trust

“Suicide is a distressing situation ambulance staff face during the course of their duties, which they do not feel adequately trained to handle. This study provides rich insights into the complexity of this care interaction, which is consistent with other similar studies. However, this enquiry provides new understandings of the interaction between ambulance staff, bereaved families and individuals during attendance at a suicide, along with the subsequent job-related strain that occurs following such exposure to suicide.

“It has long been recognised that ambulance staff are at increased risk of trauma, stress, and mental health related sickness than other staff groups. Ambulance services internationally are therefore introducing a range of initiatives to promote wellbeing and resilience of their staff, which has become increasingly important due to the COVID-19 pandemic and the known negative impact on the mental health of health. This is an important study in an under-researched area, and serves as a timely opportunity to highlight the trauma and job-related strain experienced by ambulance staff and opportunities to address the unmet support needs of ambulance staff.”

Jane Boland, Occupational Therapist 

“The impact of bereavement by suicide is being increasingly acknowledged as a significant risk factor for suicide for those experiencing it. A ‘postvention’ response for individuals and affected communities is prescribed in all local Suicide Prevention Plans. We have recently been commissioned by our local Clinical Commissioning Group to provide support to individual men who identify bereavement by suicide as a precipitant to their own suicidal crisis. This has included those who have experienced this as part of their occupational role.

“The research supports our efforts to continue to reach out to our local ‘Blue Light Services’ – including ambulance services – to ensure that referral pathways are accessible to men who need it. During the lockdown frontline staff have been offered additional support, but I am unclear about the level of take up.

“I think the research highlights that the impact of COVID-19 is likely to be long term. There is some evidence that supportive debriefing and fast access to therapy following a trauma can be effective in reducing the longer term impact, but I would suggest that a comprehensive therapy ‘offer’ to frontline staff and not a one size fits all approach is likely to be most effective.”

Public health messages on alcohol need to consider how and why people drink, not just how much

Read the Alert on public health messages

Professor Andrew Grant, GP and Chair in Clinical Education at Swansea University

“Wallace and colleagues remind us that consumption of alcohol is believed to have increased in lockdown due to coronavirus. They conducted a qualitative study interviewing patients who had been advised to reduce their alcohol intake. The perceptions of those patients were worthy of note. They did not think that an excessive alcohol consumption per se was of concern. They were aware of safe drinking limits, but they were not unduly concerned of the effects of exceeding these limits on their health. Rather, they saw ‘problem drinking’ as drinking in a pattern that suggested dependence such as needing a drink or drinking to get drunk. The implications of these findings might be that a lot of people currently drinking in excess of recommended limits do not see themselves as having a problem with alcohol.”

Support programme for GP practices increases referrals for domestic abuse

Read the Alert on this support programme for GP practices

Professor Andrew Grant, GP and Chair in Clinical Education at Swansea University

“Sohal and colleagues demonstrate how a combination of good practitioner education and a clear, easily accessible referral route increases, dramatically, the number to a dedicated domestic violence unit. It is with insight and humility that they point out to the reader that, although, their interventions result in a many-fold increase in referrals that these referrals still are only a small percentage of the number of acts of domestic violence believed to be taking place. It is for this reason that the authors emphasise that further research is required to increase the number of referrals to a point nearer to the number of episodes of domestic abuse believed to be taking place in the community.”

High rates of delirium, persistent fatigue and post-traumatic stress disorder were common after severe infection in previous coronavirus outbreaks

Read the Alert on the symptoms after coronavirus infections

Eric Deeson, public involvement volunteer with the Alzheimer’s Society

“The Lancet paper is a review of only a few dozen small studies; Norman Poole mentions other weaknesses. Even so, it’s of interest as it warns of mental symptoms that are only slowly coming into lists of typical but not very common COVID-19 after-effects. Examples are post-traumatic stress disorder (PTSD) and memory and sleep impairment.

“My own acute COVID-19 in March was marked only by high fever (i.e. no dry coughing fits, the other marker at the time in the UK). My main after-effects are breathlessness and occasional fatigue (neither striking me as being aspects of mental health), and a major change in sleep pattern (which is). But my wife reminds me that I had mental fatigue for a month or so, though I’d describe that as apathy… but even now, in August 2020, we can’t generalise about the mental after-effects of COVID-19. The Alert recommends that health staff be aware of such things as anxiety, depression and PTSD. Family members and employers may need to be aware too: for these may appear many months into the future."

Aerobic exercise is an effective treatment for depression

Read the Alert on aerobic exercise

Dr. Laura Stevenson, higher trainee in general and older adult psychiatry

“Research has demonstrated a significant number of benefits that maintaining a healthy lifestyle can have on physical health. As part of a healthy lifestyle, engaging in regular exercise is recommended.

“As a psychiatrist, I am all too aware that my patients have a greater overall morbidity and mortality rate than observed in the general population. The reasons for this are multifactorial and include the mental disorder for which they are receiving treatment itself; increased tobacco and alcohol use; higher obesity rates; and less physical activity.

“Research has also focussed on the mental health benefits obtained by undertaking regular exercise. Previous studies examining the use of exercise as a treatment for depression gave somewhat varied results, in part, due their design. This more recent systematic review, using meta-analysis of a number of high quality studies, was able to demonstrate a clinically significant reduction in depressive symptoms in those patients with a diagnosis of major depression. How the exercise was undertaken (individually or as part of a group), and the nature of the exercise did not alter the results.

“This study supports my advice to patients suffering from depression regarding the importance of making time to exercise in order to help themselves feel better. This can be very empowering. All the exercise undertaken in the review was of a supervised nature which is not likely to be replicable on a large scale, especially given the current COVID-19 pandemic. The study does identify however that exercise performed on an individual basis, such as walking, and exercise outdoors, is equally as effective as other forms, and may be safer and more acceptable to patients in the current climate.”

Therapists and patients have good quality interactions during telephone sessions

Read the Alert telephone sessions for therapy

Dr. Laura Stevenson, higher trainee in general and older adult psychiatry

“Traditionally, appointments which occur on a face-to-face basis have been the mainstay of healthcare provision, and in mental health settings, I have witnessed the concerns of staff that any other type of interaction is automatically of a lesser quality simply due to its nature.  With the occurrence of the COVID-19 pandemic and resulting lockdown, services have had to adapt quickly in order to continue to provide treatment via alternative methods.

“This study, which forms part of a larger project, was able to demonstrate that there were no significant differences when therapy for the treatment of mild to moderate mental health problems was undertaken using telephone, rather than face-to-face sessions.  This provides valuable reassurance for both professionals and patients that high quality care can continue to be achieved. The impact of COVID-19 means we are unlikely to return to a normal way of life in the near future, and research such as this provides support for alternative ways of working having a lasting place in healthcare.

“As a psychiatrist, I would be interested to learn whether the same results are replicated for outpatient clinic appointments. Certainly in my experience, I have been able to achieve what was needed, and patients have not reported significant dissatisfaction or particular concerns. There are numerous benefits to not having to travel to attend an appointment and it is therefore imperative that we continue to offer this solution to patients who prefer it in the longer term.”

Loneliness, but not social isolation, predicts development of dementia in older people

Read this Alert on loneliness in dementia

Dr. Rebecca Chubb, Locum Consultant Psychiatrist 

“This interesting long term study shows us the importance of human connection and reveals real insight into what help and services we need predict in the wake of the COVID-19 pandemic.

“It has long been known that social contact is, in general, good for memory but this teases out what that really means and is often the case, things are more complex than we thought. Merely having a stranger pop in may be helpful in many ways, but this study would suggest that there is something about the quality of the connection not just the frequency.

“As humans we are wired to connect to others, to feel a purpose, a belonging and be part of a community. This feels intuitive but we now have evidence to suggest that it is not only a desirable feature to have in our lives, without it our brains simply don’t function as well.

“Alas, a true connection is not always something that can be quickly or easily found. Whilst social care and health services need to be aware of this, it really is something which as a society we need to consider. Building a network of people who make us feel connected and therefore not lonely, even if they live miles away is something we should all be thinking about much earlier in our lives.”

Eric Deeson, public involvement volunteer with the Alzheimer’s Society

“As a fairly healthy male in my late 70s, when COVID-19 appeared I wasn’t asked to be 'shielded' (or 'shrouded' as a friend who got the shielding letter calls it.) When COVID-19 struck me, I felt too poorly for two or three weeks to think of going out – or to feel lonely. But I wasn’t alone: my wife kept me going (fair enough – she’d given me the COVID-19, but was much better herself by then). Our younger daughter came over two or three times, with shopping and plenty of good cheer; we all reckon she’d been the source of our illness.

“But in my adult life (at least) I’ve hardly, if ever, felt lonely, even with my wife away for weeks. And I’ve never had more than one or two close non-family relationships (often none); that means a high level of social isolation, according to this study. I’ve always believed that my being male explains both. This paper treats the degrees of perceived loneliness and social isolation as separate. It also tells us that the former links significantly to dementia development, while the latter has little of no effect. I’ve no problem with any of that. Yet, I’d love to know whether the sexes differ significantly in perceived loneliness. The paper’s data doesn’t cover this.

“Thus this pre COVID-19 research concludes that feeling lonely is a risk factor for developing dementia, while social isolation isn’t. This is probably not intuitive, so deserves thought by health and social care professionals and by family members of over-65s at least.”

Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

Learn more about our contributors

Dr. Rebecca Chubb
Rebecca works as a Locum Consultant Psychiatrist at North Staffordshire Combined Healthcare NHS Trust. She is the Clinical Lead for Older Persons Services. She works in memory clinics, care homes and in a liaison service, seeing patients in a general hospital who require an assessment and support of their mental health. Rebecca is passionate about ensuring Older People have equal access to mental health services and are afforded the respect and dignity they deserve. She also has an interest in frailty and end of life dementia care.

Dr. Godfred Boahen

Dr. Godfred Boahen is the Policy, Research and Practice Improvement Lead at the British Association of Social Work, the UK professional body. Godfred is a qualified social worker with practice expertise in children's social care. Godfred's PhD was in integrated care for BME people with learning disabilities. He was a member of the BAME Communities Advisory Group, Social Care Sector COVID-19 Support Taskforce.

Sarah Bodell

Sarah is an HCPC Registered Occupational Therapist, graduating in 1991. Sarah has worked in clinical practice, service management and education in voluntary, private and statutory provision. Sarah is the Director of Occupational Therapy at the University of Salford.

Debs Smith 

Debs has had mental health issues since the age of 18 and accessed services since then for many years. She has arthritis and fibromyalgia. Debs now leads a full and active life and has been active in PPI (Patient and Public Involvement) work for the last nine years as well as a varied volunteering roles.

Jane Boland 

Jane qualified as an Occupational Therapist in 2001 and has  worked in mental health since then, mainly working in frontline NHS services assessing and treating people in an acute mental crisis. Jane was the Suicide Prevention Lead for Merseycare NHS Trust and coproduced the ZSA SeeSaySignpost Training which has now been accessed by over half a million people.

Jane’s expertise in suicide prevention led to her appointment as Clinical Lead for James’ Place, where she developed a therapeutic model and recruited and trained the team who deliver a unique and innovative therapy to men in suicidal crisis.

Danielle Rogers

Danielle is a UK registered pharmacist with over 30 years of experience in clinical practice within a range of healthcare settings ranging from secondary care to CCG/primary care/STP and most recently in mental health services. She is a specialist mental health pharmacist with a specialist interest in optimising medicines in people with learning disabilities and has had several publications in this field. Danielle has worked within numerous multidisciplinary settings, both academically and in clinical practice; she is a member of the Royal College of Psychiatrists Quality Network for Learning Disability Accreditation and Advisory Committee. Danielle is currently carrying out a PhD at the Centre for Educational Development, Appraisal and Research at the University of Warwick, examining the evidence base of the effects and processes of deprescribing psychotropic medicines in people with learning disabilities.

Nigel Rees

Nigel is Head of Research and Innovation for the Welsh Ambulance Services NHS Trust (WAST), and also Health and Care Research Wales Co Trauma & Emergencies Specialty Lead. He is a Paramedic, and has worked in the UK Emergency Ambulance Service since 1989. Nigel has research interests in Pre-hospital and emergency care including mental health care provision and has published over 70 peer reviewed journal articles. Nigel is a Fellow of the College of Paramedics and was awarded the Queens Ambulance Medal in the 2017 New Years honours list for distinguished or meritorious service.

Professor Andrew Grant

Andrew has practised as a GP for 34 years but an increasing proportion of his career in the last 25 years has been in medical education. As a year director and dean of medical education, he became aware of the number of medical students who were suffering with severe mental health conditions and his more recent research has focussed on the provision of support for medical students and junior doctors with mental illness. In 2012, Andrew led a team of researchers who were commissioned by the General Medical Council to explore sources of support for medical students with mental health conditions.

Eric Deeson

After a career in education and training (and a moonlighting one as a writer and editor), Eric became entranced by public involvement (PI) in health / care research. About eight years in, he is a full-time PI volunteer nationwide, working with various charities, arms of NIHR and equivalent, and hospitals and universities. Eric was diagnosed with Alzheimer’s seven years ago.

Dr. Laura Stevenson 

Laura is a higher trainee in general and older adult psychiatry, based at North Staffordshire Combined Healthcare NHS Trust in the West Midlands.  She is co-secretary of the Psychiatric Trainees Committee at the Royal College of Psychiatrists and has an interest in medical education, digital health and improving access to services, and physical health promotion.

With thanks to the Clinical Research Network West Midlands and the Royal College for Occupational Therapists for their collaboration on this Collection.

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