What are effective psychosocial responses based on regional or national response plans during and following public health emergencies?

Section I: Evidence from 1 August to 14 December 2020

Please note that Section I should be read in conjunction with Section II, the original summary from July 2020. 

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The following information resources have been selected by the National Health Library and Knowledge Service Evidence Virtual Team in response to your question. The resources are listed in our estimated order of relevance to practicing healthcare professionals confronted with this scenario in an Irish context.  In respect of the evolving global situation and rapidly changing evidence base, it is advised to use hyperlinked sources in this document to ensure that the information you are disseminating to the public or applying in clinical practice is the most current, valid and accurate. For further information on the methodology used in the compilation of this document ¾ including a complete list of sources consulted ¾ please see our National Health Library and Knowledge Service Summary of Evidence Protocol.

Main Points

  1. A significant number of mental health problems will emerge in the general population as a result of the pandemic.
  2. Additional risk groups include women and the elderly.
  3. Additional triggers include excessive exposure to media coverage, reduced physical exercise, excessive online gaming and increased screen time.
  4. Interventions include the management of media exposure, the tailoring of information provision to take account of specific population groups and the promotion of physical activity and group membership.
  5. There is a requirement for reform in the structure and delivery of mental health services.
  6. Surveillance of social media can be used to identify population level changes in mental health that have yet to emerge as a result of the pandemic.

Summary of Evidence

While earlier studies have suggested that the majority of the general population will emerge from the pandemic unscathed with regard to mental health status, emerging evidence suggests that this might not be the case and that there will be significant mental health problems to be addressed11,12,31,32. Additional at risk groups have been identified, including the elderly4,7 and women8,11 and the vulnerability of younger people (≥ 18) and adolescents has been confirmed11,12,26. Further triggers to the development of mental health issues include excessive exposure to media coverage17, reduced exercise5, online gaming which, while having a positive effect in respect of social isolation, can, in excess, lead to the development of gaming disorder13, 15, and excessive screen time, both in the context of work and leisure22.

Recent studies have suggested a wide range of population level mental health interventions, with some authors asserting that interventions that were previously aimed at individuals or smaller groups could be scaled up to the general population25, 18.  Potential interventions include:  the management of media exposure in order to manage misinformation16, 17;the use of smartphones and apps18, 20, 25, although one author cautions with regard to the limitations of smartphone apps in the treatment of trauma20; and the tailoring of information or advertising campaigns to take account of different age groups7  or health disparities6.  Other studies explore the promotion of increased physical activity4, 5, 12, with one author proposing that access to public parks in urban areas should be managed in order to facilitate social distancing29. Additional interventions include group-based CBT32, psychological first aid32, self-affirmation28; the promotion of group membership and social identity1; transdiagnositic mental health maintenance2 ; and the use of a pamphlet to help adults to support emotions in children and adolescents26. One study protocol aims to examine the use of multi-level interventions in promoting mental health in businesses and public work places33. It is interesting to note that one study reports an intervention ¾ expressive writing ¾ that actually increased stress levels in participants, and comments that not all interventions are appropriate within the context of a pandemic or similar crisis19. This note of caution is echoed by Yue et al32, who comment that the usefulness and limitations of remote delivery of health services should also be recognised.

Several authors identify a need, exposed by the pandemic, for major reform in the way in which mental health services are structured and delivered10, 21, 23, 24, 27, 30, and one author comments specifically on the need for balance between national leadership and local adaptation of evidence27.Another author comments that there can be no effective mental health response to the pandemic without taking account of economics and politics, exploring the environments that make people ill and providing support to do something about these issues, including the provision of debt relief to low and middle income countries3.  There is also a need to increase mental health literacy in the general population32.

Several authors suggest that continued surveillance of social media via Google Trends or Twitter should be carried out in order to identify population level changes in mental health9, 14, with one author asserting that surveillance is warranted in order to identify changes in population mental health that have yet to emerge as the result of the pandemic.

Irish and/or International Guidance

Alcover, CM et al (2020) Group Membership and Social and Personal Identities as Psychosocial Coping Resources to Psychological Consequences of the COVID-19 Confinement[1]

The confinement imposed by measures to deal with the COVID-19 pandemic may in the short and medium term have psychological and psychosocial consequences affecting the well-being and mental health of individuals. This study aims to explore the role played by group membership and social and personal identities as coping resources to face the experience of the COVID-19 confinement and radical disruption of social, work, family and personal life in a sample of 421 people who have experienced a month of strict confinement in the Region of Madrid. Our results show that identity-resources such as membership continuity/new group memberships and personal identity strength are positively related to process-resources such as social support and perceived personal control, and that both are related to better perceived mental health, lower levels of anxiety and depression, and higher well-being, life satisfaction and resilience during confinement. These results, in addition to providing relevant information about the psychological consequences of this experience, constitute a solid basis for the design of psychosocial interventions based on group memberships and social identity as coping resources.

Arnold, T et al (2020) A brief transdiagnostic pandemic mental health maintenance intervention[2]

The COVID-19 pandemic qualifies as a major national and global disaster. Behavioral health providers are poised to provide psychological crisis interventions to reduce the psychosocial effects. This paper presents a brief transdiagnostic mental health maintenance intervention tailored to treat adults and families with distress symptoms. The intervention components include evidence-based techniques which have been strategically selected to address distress related to the pandemic and to prevent the escalation of distress. The intervention aims to be flexibly incorporated into care based on the provider and needs of the presenting individuals. The intervention incorporates components of evidence-based treatments such as Cognitive Behavioral Therapy and associated third wave therapies such as Dialectical Behavioral Therapy and Acceptance and Commitment Therapy. The intervention can be delivered via telehealth and includes the following modules: 1 Agenda Setting and Avoidance Identification; 2 Responding to Difficult News/Normalizing Reactions; 3 Perspective Taking; 4 Situational Control/Acceptance; 5 Maintaining a Healthy Routine; 6 Coping with Stress; 7 Insomnia Preventions; and 8 Building Resiliency and Hope. The intervention includes a list of home based pleasurable activities, a list of technology modalities to maintain social interactions, and a handout for patients. Research is needed to further test this intervention and assess implementation strategies.

Burgess, R (2020) COVID-19 mental-health responses neglect social realities[3]

According to the author, recommendations from WHO and UK national government forget half of the equation: the need to address the social and economic conditions that contribute to poor mental health. Before COVID-19, all over the world, billions lacked access to the basic necessities that make good mental health possible. The situation is even worse now. Depression was already a leading cause of disability globally, and has been strongly associated with poverty in low- and middle-income countries.

For the author, we need a reimagining of what counts as treatment in mental health care. Right now, the COVID-19 mental-health strategy is dominated by concerns about an increase in deaths by suicide, a rise in the incidence of depression and possible neurological damage caused by the virus, and rightly so. But labelling a condition doesn’t make the social challenges around it disappear.

 If psychology and psychiatry want to be truly patient-centred, we need to develop platforms that simultaneously engage with both politics and economics. We need a practice that recognizes the environments that can make people ill, and that supports efforts to do something about it.

Does a telephone counselling service connect people to food banks or to charities that provide emergency shelter if they fear domestic violence? It should. Are mental-health campaigns arguing for better social protections so that unemployed people don’t fear death from starvation during lockdown? They should. Want to ensure this at scale? Support calls for debt relief in low- and middle-income countries so that they can afford to shift money to where it is most needed. Such approaches will prevent some of the most vulnerable people from becoming mentally ill in regions that lack the capacity to deal with compounding crises. They will also make a huge difference to the lives of those with existing mental-health conditions.

Carriedo, A et al (2020) COVID-19, Psychological Well-being and Physical Activity Levels in Older Adults During the Nationwide Lockdown in Spain[4]

Objective: The novel coronavirus disease (COVID-19) has forced nationwide lockdowns in many countries. As a result, most of the Spanish population had to self-isolate at home. The physical and psychological consequences of this unexpected scenario could be particularly worrisome for people older than 60 years. This study is aimed to examine the psychological well-being of older adults during the home isolation due to the COVID-19 pandemic and to investigate whether meeting the World Health Organization’s global recommendations on physical activity (PA) for health is associated with their resilience, affect, and depressive symptoms.

Design, setting, and participants: In this cross-sectional study, a total of 483 citizens whose ages ranged from 60 to 92 years (overall sample: M = 65.49, SD = 5.14) were recruited via a snowball sampling strategy to answer to an online questionnaire.

Measurements: The four instruments used were The Connor-Davidson CD-RISC resilience scale, The Positive and Negative Affect Schedule, the six-item self-report scale of Depressive Symptoms, and The international Physical Activity Questionnaire.

Results: Results showed that older adults who regularly engaged in vigorous (VPA) and moderate-vigorous physical activity (MVPA) during the quarantine reported higher scores in resilience (Locus, Self-efficacy, and Optimism), positive affect, and lower in depressive symptoms.

Conclusion: These finding are the first quantitative evidence pointing toward a link between engagement in VPA and/or MVPA and resilience, positive affect, and depressive symptoms within the COVID-19 restrictions in Spain. Acknowledging these associations may be important in developing health promotion programs for older people during the remaining period of confinement or future ones.

Di Sebastiano, KM et al (2020) Don’t Walk So Close to Me: Physical Distancing and Adult Physical Activity in Canada[5]

Background: In response to the COVID-19 pandemic, physical distancing measures have been implemented globally. Canadians have been instructed to stay at home, which has likely resulted in significant changes in their physical activity. Using data from a national physical activity tracking app (PAC app), we aimed to determine device-measured physical activity levels immediately prior to and following the implementation of physical distancing measures in Canada to provide evidence for the development of physical activity recommendations for future pandemics or second wave infections. Methods: Demographic and physical activity data were extracted from the ParticipACTION app (PAC app), using a 10-week (10 February to 19 April 2020) quasi-experimental design to determine changes in physical activity 4 weeks pre-pandemic and 6 weeks post-pandemic declaration. Weekly physical activity levels were monitored through wearable fitness trackers and health apps linked to the PAC app, to record moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and steps. Repeated measure ANOVA was used to determine changes over time (mean ± SE). Findings: A total of 2,338 Canadians who were mostly 35-44 years old (26.6%) and female (90.2%) were included in the analysis. MVPA, LPA, and steps significantly declined immediately following the declaration of the pandemic (MVPA: pre-pandemic: 194.2 ± 5.2 min, post-pandemic: 176.7 ± 5.0 min, p < 0.001; LPA: pre-pandemic: 1,000.5 ± 17.0 min, post-pandemic: 874.1 ± 15.6 min, p < 0.001; steps: pre-pandemic: 48,625 ± 745 steps, post-pandemic: 43,395 ± 705 steps, p < 0.001). However, 6 weeks following pandemic declaration, MVPA (week 6: 204.4 ± 5.4 min, p = 0.498) had returned to pre-pandemic levels. LPA (week 6: 732.0 ± 14.3 min, p = < 0.001) and steps (week 6: 41,946 ± 763, p < 0.001) remained significantly lower than pre-pandemic levels at week 6. Interpretation: Although MVPA returned to pre-pandemic levels, significant and sustained declines in incidental LPA and steps were observed. Attenuating the loss of incidental physical activity should be a public health priority in response to future pandemics or a second wave of a COVID-19 infection, as it may have significant long-term implications for the physical and mental health of Canadians.

Farmer, N et al COVID-19: Growing Health Disparity Gaps and an Opportunity for Health Behavior Discovery?[6]

Recently, racial and ethnic disparities within the current coronavirus disease-2019 (COVID-19) pandemic at the state level have received attention and notably highlight the ongoing issues surrounding health disparities within the United States. Among the discussions around health disparities lies a discussion on the role of psychosocial stress during this pandemic, especially with broadly applied social distancing and isolation recommendations. In nonpandemic times, psychosocial stressors have a significant association with physiological responses and behavioral responses. Within the current pandemic, increased attention on health-promoting behaviors, such as cooking and physical activity, has occurred. However, based on disparities from structural racism and socioeconomic effects on neighborhood environments, we may see a limiting value to the possible mitigating role of health behaviors within some disparate communities. We present in this perspective that there may be a role for behavioral interventions to mitigate psychosocial stressors and promote health behaviors. It may also be important to consider the use of multilevel behavioral interventions designed in the context of environmental and perceptual barriers during the COIVD-19 pandemic.

Gorenko, JA et al (2020) Social Isolation and Psychological Distress Among Older Adults Related to COVID-19: A Narrative Review of Remotely-Delivered Interventions and Recommendations[7]

The COVID-19 pandemic is associated with several short- and long-term negative impacts on the well-being of older adults. Physical distancing recommendations to reduce transmission of the SARS-CoV2-19 virus increase the risk of social isolation and loneliness, which are associated with negative outcomes including anxiety, depression, cognitive decline, and mortality. Taken together, social isolation and additional psychological impacts of the pandemic such as worry or grief underscore the importance of intervention efforts to older adults. This narrative review draws upon a wide range of evidence to provide a comprehensive overview of appropriate remotely-delivered interventions for older adults that target loneliness and psychological symptoms. These include interventions delivered by a range of individuals from community members to mental health professionals, and interventions that vary by implementation: eg self-guided therapy, remotely-delivered interventions via telephone or video call. Recommendations to overcome barriers to implementation and delivery are provided, with consideration given to the different living situations.

Gurvich, C et al (2020) Coping styles and mental health in response to societal changes during the COVID-19 pandemic[8]

Background: Psychosocial responses to infectious disease outbreaks have the potential to inflict acute and longstanding mental health consequences. Early research across the globe has found wide ranging psychological responses to the current COVID-19 pandemic. Understanding how different coping styles can be effective in mitigating mental ill health would enable better tailored psychological support.

Aims: The aim of this study was to gain an understanding of psychosocial responses to the COVID-19 pandemic, including depression, anxiety and distress, as well as effective coping styles in an Australian sample.

Method: A sample of 1,495 adults, residing in Australia between April 3rd and May 3rd 2020, completed an online survey which measured psychological distress (Impact of Events Scale-Revised), depression, anxiety, stress (DASS-21), as well as coping strategies (Brief COPE).

Results: 47% of the respondents were experiencing some degree of psychological distress. Females experienced higher levels of depression, anxiety and stress than males. Coping strategies associated with better mental health were positive reframing, acceptance and humour. Conversely, self-blame, venting, behavioural disengagement and self-distraction were associated with poorer mental health.

Conclusion: Rates of psychological symptoms amongst the Australian population are similar to those reported in other countries. Findings add to the growing literature demonstrating a gender disparity in the mental health impacts of COVID-19. Positive emotion focused coping strategies may be effective for reducing psychological symptoms. Understanding psychosocial responses including beneficial coping strategies are crucial to manage the current COVID-19 situation optimally, as well as to develop mental health response plans for future pandemics.

Hoerger, M et al (2020) Impact of the COVID-19 pandemic on mental health: Real-time surveillance using Google Trends[9]

In the wake of COVID-19, the capacity to track emerging trends in mental health symptoms and needs will guide public health responses at multiple ecological levels. Using Google Trends to track population-level mental health-related Google searches in the United States, this investigation identified pandemic-associated spikes in searches related to anxiety symptoms and remote treatments for anxiety, such as deep breathing and body scan meditation. As other discernable population-level changes in mental health have yet to emerge, continued surveillance is warranted.

Javakhishvili, JD et al (2020) Trauma-informed responses in addressing public mental health consequences of the COVID-19 pandemic: position paper of the European Society for Traumatic Stress Studies (ESTSS)[10]

The COVID-19 pandemic has changed life in Europe and globally. The pandemic affects both individuals and the broader society across many domains, including physical and psychological health, the economy and general welfare. The measures taken to counteract the pandemic have significantly altered daily life and, along with the threat of contracting the coronavirus and uncertainties surrounding future developments, created a complex system of stressors with a negative impact on public mental health. This paper aims to outline the ESTSS strategy to address mental health issues related to COVID-19 and focuses on trauma-informed policies, capacity building, collaborative research and knowledge-exchange. To facilitate implementation of a trauma-informed approach and appropriate measures, ESTSS has developed a toolkit of recommendations on mental health and psychosocial assistance to be provided during the different phases of crisis and its aftermath. To promote capacity building, ESTSS offers a certification programme based on a curriculum in psychotraumatology and corresponding on-line training to the European community of mental health professionals. To assure evidence-based approaches and methods tailored to current circumstances, ESTSS has initiated a pan-European research project with international cooperation aimed at studying the mental health consequences of the pandemic, with a focus on psychological trauma and other stress-related reactions. To foster knowledge-exchange, the European Journal of Psychotraumatology (EJPT), the official journal of ESTSS, is publishing a special issue on COVID-19.

Jia, R et al (2020) Mental health in the UK during the COVID-19 pandemic: cross-sectional analyses from a community cohort study[11]

Objectives: Previous pandemics have resulted in significant consequences for mental health. Here, we report the mental health sequelae of the COVID-19 pandemic in a UK cohort and examine modifiable and non-modifiable explanatory factors associated with mental health outcomes. We focus on the first wave of data collection, which examined short-term consequences for mental health, as reported during the first 4-6 weeks of social distancing measures being introduced.

Design: Cross-sectional online survey.

Setting: Community cohort study.

Participants: N=3097 adults aged ≥18 years were recruited through a mainstream and social media campaign between 3 April 2020 and 30 April 2020. The cohort was predominantly female (n=2618); mean age 44 years; 10% (n=296) from minority ethnic groups; 50% (n=1559) described themselves as key workers and 20% (n=649) identified as having clinical risk factors putting them at increased risk of COVID-19.

Main outcome measures: Depression, anxiety and stress scores.

Results: Mean scores for depression ([Formula: see text] =7.69, SD=6.0), stress ([Formula: see text] =6.48, SD=3.3) and anxiety ([Formula: see text] = 6.48, SD=3.3) significantly exceeded population norms (all p<0.0001). Analysis of non-modifiable factors hypothesised to be associated with mental health outcomes indicated that being younger, female and in a recognised COVID-19 risk group were associated with increased stress, anxiety and depression, with the final multivariable models accounting for 7%-14% of variance. When adding modifiable factors, significant independent effects emerged for positive mood, perceived loneliness and worry about getting COVID-19 for all outcomes, with the final multivariable models accounting for 54%-57% of total variance.

Conclusions: Increased psychological morbidity was evident in this UK sample and found to be more common in younger people, women and in individuals who identified as being in recognised COVID-19 risk groups. Public health and mental health interventions able to ameliorate perceptions of risk of COVID-19, worry about COVID-19 loneliness and boost positive mood may be effective.

Jung, S et al (2020) Mental Health, Sense of Coherence, and Interpersonal Violence during the COVID-19 Pandemic Lockdown in Germany[12]

Preliminary data indicates that the Coronavirus SARS-CoV-2 disease (COVID-19) pandemic may have a substantial impact on mental health and well-being. We assessed mental health in response to the lockdown in Germany between 1 April 2020 and 15 April 2020 using a cross-sectional online survey (n = 3545) with a mixed-methods approach. We found increased levels of psychosocial distress (Patient Health Questionnaire (PHQ) stress module), anxiety, depressive symptoms (PHQ-4), irritability, and a decrease in overall well-being (WHO-Five Well-Being Index (WHO-5)), sense of coherence (Short Form of the Sense of Coherence Scale (SOC-L9)), sexual contentment, and sleep quality. The four-week-prevalence of interpersonal violence was yet at 5% and included verbal, physical, and sexual violence. Participants reported finding comfort in family, friends, conversation, exercise, and activity. Findings are also in line with research showing that women seem to have more trouble coping with the pandemic and lockdown measures. Our observations demonstrate that the COVID-19 pandemic and related measures lead to a mental health burden even in a highly developed Western country and should, therefore, be taken seriously. The findings for interpersonal violence are alarming. Thus, we should sharpen our focus on the matter and activate and enhance supporting systems to help protect those affected.

King, DL et al (2020) Problematic online gaming and the COVID-19 pandemic[13]

Stay-at-home mandates and quarantines related to the coronavirus (COVID-19) pandemic have led to greatly increased participation in online gaming. Initiatives such as #PlayApartTogether that promote gaming for socializing and stress reduction may achieve positive outcomes. Although gaming can be a healthy coping strategy for the majority, it can also pose risks to some vulnerable individuals. Protracted periods of social isolation and technology-based activity pose the danger of solidifying unhealthy lifestyle patterns, leading to difficulties to readaptation when the COVID-19 crisis has passed. Balanced and effective approaches to gaming during the COVID-19 pandemic are needed to support physical and psychological wellbeing.

Knipe, D et al (2020) Mapping population mental health concerns related to COVID-19 and the consequences of physical distancing: a Google trends analysis[14]

Background: The 2020 Coronavirus pandemic is a major international public health challenge. Governments have taken public health protection measures to reduce the spread of the virus through non-pharmalogical measures. The impact of the pandemic and the public health response on individual and population mental health is unknown. Methods: We used Google Trends data from 1 Jan 2020 – 30 March 2020 to investigate the impact of the pandemic and government measures to curb it on people’s concerns, as indexed by changes in search frequency for topics indicating mental distress, social and economic stressors and mental health treatment-seeking. We explored the changes of key topics in Google trends in Italy, Spain, USA, UK, and worldwide in relation to sentinel events during the pandemic. Results: Globally there appears to be significant concerns over the financial and work-related consequences of the pandemic, with some evidence that levels of fear are rising. Conversely relative searching for topics related to depression and suicide fell after the pandemic was announced, with some evidence that searches for the latter have risen recently. Concerns over education and access to medication appear to be particular social stressors. Whilst searches for face-to-face treatments have declined, those for self-care have risen. Conclusions: Monitoring Google trends shows promise as a means of tracking changing public concerns. In weeks to come it may enable policy makers to assess the impact of their interventions including those aiming to limit negative consequences, such as government funded financial safety nets.

KO, CH et al (2020) Impact of COVID-19 on gaming disorder: monitoring and prevention[15]

The global coronavirus disease 2019 (COVID-19) outbreak has necessitated physical distancing, lockdown, contact tracing, and self-quarantine so as to prevent the spread of the disease. Amid the outbreak, gaming data usage has reportedly increased in the United States, and game download volume has reached a record high in Europe. Because gaming can be used to cope with the psychological stress from the outbreak, therefore mental health professionals should be aware of how increased gaming during the pandemic may contribute to risk of gaming disorder, especially if the pandemic persists. Mental health professionals should thus formulate safe social interaction alternatives for people, particularly adolescents, who have gaming disorder risk.

LIU, JCJ et al (2020) The Relation Between Official WhatsApp-Distributed COVID-19 News Exposure and Psychological Symptoms: Cross-Sectional Survey Study[16]

Background:In a global pandemic, digital technology offers innovative methods to disseminate public health messages. As an example, the messenger app WhatsApp was adopted by both the World Health Organization and government agencies to provide updates on the coronavirus disease (COVID-19). During a time when rumors and excessive news threaten psychological well-being, these services allow for rapid transmission of information and may boost resilience.

Objective:In this study, we sought to accomplish the following: 1 assess well-being during the pandemic; 2 replicate prior findings linking exposure to COVID-19 news with psychological distress; and 3 examine whether subscription to an official WhatsApp channel can mitigate this risk.

Methods:Across 8 weeks of the COVID-19 outbreak (March 7 to April 21, 2020), we conducted a survey of 1145 adults in Singapore. As the primary outcome measure, participants completed the Depression, Anxiety, and Stress Scale (DASS-21). As predictor variables, participants also answered questions pertaining to the following: 1 their exposure to COVID-19 news; 2 their use of the Singapore government’s WhatsApp channel; and 3 their demographics.

Results:Within the sample, 7.9% of participants had severe or extremely severe symptoms on at least one DASS-21 subscale. Depression scores were associated with increased time spent receiving COVID-19 updates, whereas use of the official WhatsApp channel emerged as a protective factor (b=-0.07, t[863]=-2.04, P=.04). Similarly, increased anxiety scores were associated with increased exposure to both updates and rumors, but this risk was mitigated by trust in the government’s WhatsApp messages (b=-0.05, t[863]=-2.13, P=.03). Finally, although stress symptoms increased with the amount of time spent receiving updates, these symptoms were not significantly related to WhatsApp use.

Conclusions:Our findings suggest that messenger apps may be an effective medium for disseminating pandemic-related information, allowing official agencies to reach a broad sector of the population rapidly. In turn, this use may promote public well-being amid an “infodemic.”

LOOI, JC et al (2020) Clinical update on managing media exposure and misinformation during COVID-19: recommendations for governments and healthcare professionals[17]

Objectives:To provide a clinical update on the mechanisms of, and potential population mental health risks of, excessive media exposure and misinformation regarding the COVID-19 pandemic. To outline guidance for government, health services, psychiatrists and health professionals in managing mental health effects of COVID-19 media exposure.

Conclusions:Social and traditional media businesses attract interest by reporting threats and negativity, and heavy media exposure during disasters is associated with increased depressive and post-traumatic symptoms. There are three main recommendations for mitigation of the adverse population mental health effects of excessive media exposure and misinformation. Clear, authoritative communication from governments, health authorities and health professionals is essential, combined with correction of misinformation and addressing mistrust. Specific warnings by governments, health authorities and clinicians of the potential adverse mental health consequences of excessive COVID-19 media consumption are needed. Limitation of exposure to media and disinformation regarding COVID-19 is crucial – the less, the better. Healthcare professionals can advise patients to check information once daily, and be guided by reliable public health authorities, as part of interventions for managing the mental health impact of COVID-19.

MARCINIAK, MA et al (2020) Standalone Smartphone Cognitive Behavioral Therapy-Based Ecological Momentary Interventions to Increase Mental Health: Narrative Review[18]

Background:A growing number of psychological interventions are delivered via smartphones with the aim of increasing the efficacy and effectiveness of these treatments and providing scalable access to interventions for improving mental health. Most of the scientifically tested apps are based on cognitive behavioral therapy (CBT) principles, which are considered the gold standard for the treatment of most mental health problems.

Objective:This review investigates standalone smartphone-based ecological momentary interventions (EMIs) built on principles derived from CBT that aim to improve mental health.

Methods:We searched the MEDLINE, PsycINFO, EMBASE, and PubMed databases for peer-reviewed studies published between January 1, 2007, and January 15, 2020. We included studies focusing on standalone app-based approaches to improve mental health and their feasibility, efficacy, or effectiveness. Both within- and between-group designs and studies with both healthy and clinical samples were included. Blended interventions, for example, app-based treatments in combination with psychotherapy, were not included. Selected studies were evaluated in terms of their design, that is, choice of the control condition, sample characteristics, EMI content, EMI delivery characteristics, feasibility, efficacy, and effectiveness. The latter was defined in terms of improvement in the primary outcomes used in the studies.

Results:A total of 26 studies were selected. The results show that EMIs based on CBT principles can be successfully delivered, significantly increase well-being among users, and reduce mental health symptoms. Standalone EMIs were rated as helpful (mean 70.8%, SD 15.3; n=4 studies) and satisfying for users (mean 72.6%, SD 17.2; n=7 studies).

Conclusions:Study quality was heterogeneous, and feasibility was often not reported in the reviewed studies, thus limiting the conclusions that can be drawn from the existing data. Together, the studies show that EMIs may help increase mental health and thus support individuals in their daily lives. Such EMIs provide readily available, scalable, and evidence-based mental health support. These characteristics appear crucial in the context of a global crisis such as the COVID-19 pandemic but may also help reduce personal and economic costs of mental health impairment beyond this situation or in the context of potential future pandemics.

MARKOVIC, MV et al (2020) Effectiveness of Expressive Writing in the Reduction of Psychological Distress During the COVID-19 Pandemic: A Randomized Controlled Trial[19]

Objective:Due to the wide impact of the COVID-19 pandemic on mental health, the need for scalable interventions that can effectively reduce psychological distress has been recognized. Expressive writing (EW) can be beneficial for different conditions, including depression, suicidal ideation, and coping with trauma. Therefore, we aim to assess the applicability and effectiveness of an online format of EW in the reduction of psychological distress in context of the COVID-19 pandemic.

Methods:In this parallel-group, randomized controlled trial, participants (n = 120) were randomly allocated to the intervention group-who completed five EW sessions over the 2 week period-or the control group-who received treatment as usual (TAU). Participants were assessed for primary and secondary outcome measures at baseline, post-treatment, and follow-up-1-month after the treatment. The primary outcome was severity of psychological distress assessed at post-treatment, operationalized as Depression Anxiety Stress Scale (DASS) summary score. Secondary outcomes were severity of depression, anxiety, and stress (DASS subscale scores), well-being (WHO-5), subjective perception of quality of life (SQOL), and subjective evaluation of difficulties coping with pandemic, which were also assessed at post-treatment. Per protocol, analysis was conducted with available cases only.

Results:A less favorable outcome was found in the intervention group on psychological distress, and symptoms of stress, after controlling for baseline scores. Increased stress was recorded in the treatment group, with no effect in the control group. There was no significant difference between the groups on depression, anxiety, well-being, and subjective quality of life. No group effect for any of the outcomes measures was recorded at follow-up. Additional analysis revealed moderation effects of age and gender with older and male participants scoring higher on distress measures.

Conclusion:Engaging in EW during the pandemic was found to elevate stress; thus, when applied in the context of the COVID-19 pandemic, it may be harmful. Hence, EW or similar self-guided interventions should not be applied without prior evidence on their effects in the context of a pandemic and similar stressful and unpredictable circumstances.

MARSHALL, JM et al (2020) Treating Psychological Trauma in the Midst of COVID-19: The Role of Smartphone Apps[20]

With the COVID-19 pandemic confronting health systems worldwide, medical practitioners are treating a myriad of physical symptoms that have, sadly, killed many thousands of people. There are signs that the public is also experiencing psychological trauma as they attempt to navigate their way through the COVID-19 restrictions impinging on many aspects of society. With unprecedented demand for health professionals’ time, people who are unable to access face-to-face assistance are turning to smartphone apps to help them deal with symptoms of trauma. However, the evidence for smartphone apps to treat trauma is limited, and clinicians need to be aware of the limitations and unresolved issues involved in using mental health apps.

MAULIK, PK et al (2020) Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic[21]

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.

MHEIDLY, N et al (2020) Coping With Stress and Burnout Associated With Telecommunication and Online Learning[22]

The COVID-19 pandemic substantially impacted the field of telecommunication. It increased the use of media applications that enable teleconferencing, telecommuting, online learning, and social relations. Prolonged time facing screens, tablets, and smart devices increases stress and anxiety. Mental health stressors associated with telecommunication can add to other stressors related to quarantine time and lockdown to eventually lead to exhaustion and burnout. In this review, the effects of the COVID-19 pandemic on communication and education are explored. In addition, the relationship between prolonged exposure to digital devices and mental health is studied. Finally, coping strategies are offered to help relieve the tele-burdens of pandemics.

MORENO, C et al (2020) How mental health care should change as a consequence of the COVID-19 pandemic[23]

The unpredictability and uncertainty of the COVID-19 pandemic; the associated lockdowns, physical distancing, and other containment strategies; and the resulting economic breakdown could increase the risk of mental health problems and exacerbate health inequalities. Preliminary findings suggest adverse mental health effects in previously healthy people and especially in people with pre-existing mental health disorders. Despite the heterogeneity of worldwide health systems, efforts have been made to adapt the delivery of mental health care to the demands of COVID-19. Mental health concerns have been addressed via the public mental health response and by adapting mental health services, mostly focusing on infection control, modifying access to diagnosis and treatment, ensuring continuity of care for mental health service users, and paying attention to new cases of mental ill health and populations at high risk of mental health problems. Sustainable adaptations of delivery systems for mental health care should be developed by experts, clinicians, and service users, and should be specifically designed to mitigate disparities in health-care provision. Thorough and continuous assessment of health and service-use outcomes in mental health clinical practice will be crucial for defining which practices should be further developed and which discontinued. For this Position Paper, an international group of clinicians, mental health experts, and users of mental health services has come together to reflect on the challenges for mental health that COVID-19 poses. The interconnectedness of the world made society vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating good practices that can result in sustained, efficient, and equitable delivery of mental health-care delivery. Thus, the COVID-19 pandemic could be an opportunity to improve mental health services.

NEWNHAM, EA et al (2020) The Asia Pacific Disaster Mental Health Network: Setting a Mental Health Agenda for the Region[24]

Addressing the psychological mechanisms and structural inequalities that underpin mental health issues is critical to recovery following disasters and pandemics. The Asia Pacific Disaster Mental Health Network was established in June 2020 in response to the current disaster climate and to foster advancements in disaster-oriented mental health research, practice and policy across the region. Supported by the World Health Organization (WHO) Thematic Platform for Health Emergency and Disaster Risk Management (Health EDRM), the network brings together leading disaster psychiatry, psychology and public health experts. Our aim is to advance policy, research and targeted translation of the evidence so that communities are better informed in preparation and response to disasters, pandemics and mass trauma. The first meetings of the network resulted in the development of a regional disaster mental health agenda focused on the current context, with five priority areas: 1  Strengthening community engagement and the integration of diverse perspectives in planning, implementing and evaluating mental health and psychosocial response in disasters; 2 Supporting and assessing the capacity of mental health systems to respond to disasters; 3 Optimising emerging technologies in mental healthcare; 4 Understanding and responding appropriately to addressing the mental health impacts of climate change; 5 Prioritising mental health and psychosocial support for high-risk groups. Consideration of these priority areas in future research, practice and policy will support nuanced and effective psychosocial initiatives for disaster-affected populations within the Asia Pacific region.

Pinto da Costa, M  (2020) Can social isolation caused by physical distance in people with psychosis be overcome through a Phone Pal?[25]

The current pandemic has forced many people into self-isolation and to practice social distancing. When people are physically isolated and distant from each other, technology may play a fundamental role by enabling social connection and reducing feelings of loneliness caused by this prolonged social isolation. In response to the COVID-19 pandemic, many mental health services worldwide have had to shift their routine face-to-face outpatient appointments to remote telepsychiatry encounters. The increased pressure on mental health services highlights the importance of community-led health-promotion interventions, which can contribute to preventing mental illness or their relapses, and to reduce the burden on health services. Patients with psychosis are particularly socially isolated, have sedentary lifestyles, and commonly face stigma and discrimination from the general population. At the same time, patients with psychosis value technology, are interested in, use and own smart-phones to digitally connect, and are satisfied with their use. Thus, among psychosocial interventions, a helpful resource may be “Phone Pal,” a complex intervention which facilitates remote communication between volunteers and socially isolated patients with psychosis through different smart-phone tools. While “Phone Pal” has been originally developed for people with psychosis, it may also be useful to the wider population, helping to overcome the social isolation caused by physical distancing, particularly in these times of widespread isolation. “Phone Pal” may be a potential public health resource for society, providing important support to those that may need it the most, and possibly benefit most from it.

RACCANELLO, D et al (2020) Development and Early Implementation of a Public Communication Campaign to Help Adults to Support Children and Adolescents to Cope With Coronavirus-Related Emotions: A Community Case Study[26]

Epidemics and pandemics can traumatically impact the emotional wellbeing of adults, children, and adolescents in diverse ways. This impact can be reduced by applying a range of evidence-based coping strategies. Based on previous research, we created a pamphlet-based communication campaign designed to assist adults to provide support for young people confronted with emotional distress associated with the pandemic caused by the novel coronavirus [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] and the related disease [coronavirus disease (COVID-19)] in 2020. We developed a pamphlet describing the common emotions children and adolescents report feeling in the face of disasters and the coping strategies that have proven effective in mitigating them. The target population was adults who interact with children and adolescents in both formal and informal settings. The pamphlet included basic information on this specific emergency, emotions that might be commonly experienced, and coping strategies for dealing with negative emotions. The aim of this paper is to describe the planning, development, and implementation of the campaign. First, we monitored how the media gave visibility to the campaign during the 40 days following the release of the pamphlet: it potentially reached a large audience at a national and international level through at least 216 media channels included the HEMOT® (Helmet for EMOTions) website. Second, Google Analytics™ data from the HEMOT® website enabled us to examine the characteristics of the visitors to the website and the behavior of those who viewed the pamphlet. More than 6,000 visitors, most from Europe followed by the Americas, visited the website in the first 40 days after the pamphlet publication. The webpage including the pamphlet obtained over 6,200 views, most directly or via other websites. A cluster analysis suggested that the access to the webpage did not mirror the trend concerning the new cases of COVID-19 in Italy (which increased during the central phase of the campaign) or worldwide (which continued to increase across the 40 days). Third, data gathered with a convenience sample of adults who had consulted the pamphlet provided a perspective on the comprehensibility of the messages conveyed by the pamphlet and on the utility for children and adolescents. The process we have demonstrated in this example could be replicated in different communities and settings to respond to the spread of the COVID-19 or to respond to other widespread or more localized disasters.

ROSENBERG, S et al (2020) International experiences of the active period of COVID-19 – Mental health care[27]

Aim:To summarise commonalities and variations in the mental health response to COVID-19 across different sites and countries, with a view to better understanding key steps not only in crisis management, but for future systemic reform of mental health care.

Method:We conducted a Rapid Synthesis and Translation Process of lessons learned from an international panel of experts, collecting on the ground experiences of the pandemic as it evolved in real time. Digital conferencing and individual interviews were used to rapidly acquire knowledge on the COVID-19 outbreak across 16 locations in Australia, Denmark, Italy, Spain, Taiwan, the UK, and the USA.

Results:COVID-19 has had massive impacts on mental health care internationally. Most systems were under-resourced and under-prepared, struggling to manage both existing and new clients. There were significant differences between sites, depending on the explosivity the pandemic and the readiness of the mental health system. Integrated, community mental health systems exhibited greater adaptability in contrast to services which depended on face-to-face and hospital-based care. COVID-19 has demonstrated the need for a new approach to rapid response to crisis in mental health. New decision support system tools are necessary to ensure local decision-makers can effectively respond to the enormous practical challenges posed in these circumstances.

Conclusions:The process we have undertaken has generated clear lessons for mental health policymakers worldwide, beyond pandemic planning and response to guide next steps in systemic mental health reform. Key here is achieving some balance between national leadership and local context adaptation of evidence.

SHIFENG LI et al (2020) Self-affirmation buffering by the general public reduces anxiety levels during the COVID-19 epidemic[28]

The wide and rapid spread of COVID-19 has intensely captured public attention, leading to increased mental health stress. Timely mental health care and intervention during the outbreak of COVID-19 is urgently needed not only for confirmed or suspected patients and frontline medical workers, but also for the general public.

Previous studies showed that affirmation of personal values can buffer psychological stress responses in various threat situations. The goal of the present study was to investigate whether an intervention involving refection on personal values was capable of buffering psychological stress responses during the outbreak. We recruited 220 participants who completed a questionnaire on their personal values. Those in the self-affirmation group were asked to choose and write their thoughts and feelings of a personal value that made them feel important to themselves while those in the control condition were asked to do the same for a personal value that they thought was important to others. Both groups completed a Self-rating Anxiety Scale (SAS) and Beck Depression Inventory (BDI) prior to and 7 days after intervention.

We used two-way repeated measures analysis of variance (ANOVA) to evaluate the buffer effect of value affirmation on stress responses with time of assessment as a within-subjects factor and intervention group as a between-subjects factor for anxiety and depression. Our results revealed a significant interaction between time and intervention for the reduction of anxiety. Further simple effect analysis demonstrated that the control group showed heightened levels of anxiety 7 days after intervention compared with before, whereas participants who affirmed their values did not show any increase. This effect remained significant after controlling for sex, age, educational level, and annual family income. However, no significant differences were found for depression.

SHOARI, N et al (2020) Accessibility and allocation of public parks and gardens in England and Wales: A COVID-19 social distancing perspective[29]

Visiting parks and gardens supports physical and mental health. We quantified access to public parks and gardens in urban areas of England and Wales, and the potential for park crowdedness during periods of high use. We combined data from the Office for National Statistics and Ordnance Survey to quantify: 1 the number of parks within 500 and 1,000 metres of urban postcodes (ie availability); 2 the distance of postcodes to the nearest park (ie accessibility); and 3 per-capita space in each park for people living within 1,000m. We examined variability by city and share of flats. Around 25.4 million people (~87%) can access public parks or gardens within a ten-minute walk, while 3.8 million residents (~13%) live farther away; of these 21% are children and 13% are elderly. Areas with a higher share of flats on average are closer to a park but people living in these areas visit parks that are potentially overcrowded during periods of high use. Such disparity in urban areas of England and Wales becomes particularly evident during COVID-19 pandemic and lockdown when local parks, the only available out-of-home space option, hinder social distancing requirements. Cities aiming to facilitate social distancing while keeping public green spaces safe might require implementing measures such as dedicated park times for different age groups or entry allocation systems that, combined with smartphone apps or drones, can monitor and manage the total number of people using the park.

SMITH, SL et al (2020) ‘Jack be nimble, Jack be quick  …’: mental health and psychosocial response in the time of coronavirus[30]

A comprehensive, integrated response to the coronavirus pandemic demands urgent attention to current mental health services and care, with bridging of lessons learned to date across high-, middle- and low-income settings, and their repackaging and delivery in community settings by non-specialists using new technologies. Collaborative alliances across systems and funders could be an essential ingredient to urgently actualizing such a critical imperative for local and global health. The widespread mental health consequences of COVID-19 can be used to reform mental health care delivery systems in a radical way. The ability of mental health systems and programs to ‘build back better’ from the coronavirus crisis will depend on the effectiveness of our collective adaptability and reaction now.

SOKLARIDIS, S  et al (2020) Mental health interventions and supports during COVID- 19 and other medical pandemics: A rapid systematic review of the evidence[31]

Background:Novel coronavirus pneumonia (COVID-19) is a global reminder of the need to attend to the mental health of patients and health professionals who are suddenly facing this public health crisis. In the last two decades, a number of medical pandemics have yielded insights on the mental health impact of these events. Based on these experiences and given the magnitude of the current pandemic, rates of mental health disorders are expected to increase. Mental health interventions are urgently needed to minimize the psychological sequelae and provide timely care to affected individuals.

Method:We conducted a rapid systematic review of mental health interventions during a medical pandemic, using three electronic databases. Of the 2404 articles identified, 21 primary research studies are included in this review.

Result:We categorized the findings from the research studies using the following questions: What kind of emotional reactions do medical pandemics trigger? Who is most at risk of experiencing mental health sequelae? What works to treat mental health sequelae (psychosocial interventions and implementation of existing or new training programs)? What do we need to consider when designing and implementing mental health interventions (cultural adaptations and mental health workforce)? What still needs to be known?

Conclusion:Various mental health interventions have been developed for medical pandemics, and research on their effectiveness is growing. We offer recommendations for future research based on the evidence for providing mental health interventions and supports to those most in need.

YUE, JL et al (2020) Mental health services for infectious disease outbreaks including COVID-19: a rapid systematic review[32]

The upsurge in the number of people affected by the COVID-19 is likely to lead to increased rates of emotional trauma and mental illnesses. This article systematically reviewed the available data on the benefits of interventions to reduce adverse mental health sequelae of infectious disease outbreaks, and to offer guidance for mental health service responses to infectious disease pandemic. PubMed, Web of Science, Embase, PsycINFO, WHO Global Research Database on infectious disease, and the preprint server medRxiv were searched. Of 4278 reports identified, 32 were included in this review. Most articles of psychological interventions were implemented to address the impact of COVID-19 pandemic, followed by Ebola, SARS, and MERS for multiple vulnerable populations. Increasing mental health literacy of the public is vital to prevent the mental health crisis under the COVID-19 pandemic. Group-based cognitive behavioral therapy, psychological first aid, community-based psychosocial arts program, and other culturally adapted interventions were reported as being effective against the mental health impacts of COVID-19, Ebola, and SARS. Culturally-adapted, cost-effective, and accessible strategies integrated into the public health emergency response and established medical systems at the local and national levels are likely to be an effective option to enhance mental health response capacity for the current and for future infectious disease outbreaks. Tele-mental healthcare services were key central components of stepped care for both infectious disease outbreak management and routine support; however, the usefulness and limitations of remote health delivery should also be recognized.

De Angelis, M et al (2020) H-WORK Project: Multilevel Interventions to Promote Mental Health in SMEs and Public Workplaces[33]

The authors describe the study design, research questions and methods of a large, international intervention project aimed at improving employee mental health and well-being in SMEs and public organisations. The study is innovative in multiple ways. First, it goes beyond the current debate on whether individual- or organisational-level interventions are most effective in improving employee health and well-being and tests the cumulative effects of multilevel interventions, that is, interventions addressing individual, group, leader and organisational levels. Second, it tailors its interventions to address the aftermaths of the COVID-19 pandemic and develop suitable multilevel interventions for dealing with new ways of working. Third, it uses realist evaluation to explore and identify the working ingredients of and the conditions required for each level of intervention, and their outcomes. Finally, an economic evaluation will assess both the cost-effectiveness analysis and the affordability of the interventions from the employer perspective. The study integrates the training transfer and the organisational process evaluation literature to develop toolkits helping end-users to promote mental health and well-being in the workplace.

Section II: Evidence to 1 August 2020

Main Points

  1. Potentially vulnerable groups include children and adolescents; those with pre-existing mental health conditions ;COVID survivors ;those for whom daily life is unsafe due to abuse or violence; those who have experienced bereavement; those with an intellectual disability; and those belonging to minority communities. Other triggers include financial instability, stigmatisation and loss of social support structures.
  2. Several authors discuss the merits of population-focussed interventions including the importance of issuing reliable information to the general public that will combat misleading information that can be so detrimental to mental health.
  3. It is important to build resilience at individual and societal levels.
  4. More specific public health interventions include building additional capacity to deliver Psychological First Aid, Parent-Child Interaction Therapy, the use of text messaging and other media, e-health strategies, telephone hotlines, and the distribution of print media.

Summary of Evidence

A public health approach to mental health prioritises the development of interventions that can reach far more people than clinical strategies. It can inform building models of primary prevention involving low-cost, low-intensity interventions that promote mental health literacy and self-management and secondary prevention which integrates mental health care into medical settings through collaborative care models29.

Although there is little evidence in the literature of effective psychosocial interventions following public health emergencies, including previous pandemics, some important themes can help to inform public mental health policy measures. The majority of the general population will emerge from this pandemic without any serious mental health concerns49; however, some will experience significant problems such as COVID Stress Syndrome14 or Post-Traumatic Stress Disorder (PTSD)46.

Several authors highlight the importance of identifying sections of the population most at risk and the triggers that might lead to development of ongoing mental health issues. Groups highlighted include children and adolescents9, 13; those with pre-existing mental health conditions9, 49;COVID survivors41;those for whom daily life is unsafe due to abuse or violence49, 20; those who have experienced bereavement; those with an intellectual disability41; and those belonging to minority communities49. Other triggers include food insecurity, financial instability41, 20,stigmatisation5, 10, 28, 39 and loss of social support structures39. Any public health psychosocial intervention must take account of and address these triggers, particularly economic harm and inequity which may be exacerbated by local, regional or national responses to the pandemic20, 49.

An important trigger emphasised by several authors is the impact of misinformation via social media and other means on the mental health of the general population2, 4, 18, 25. One author suggests that social media activity can be analysed to identify topics of concern to the general population and to share reliable information about the pandemic2.

Numerous authors discuss the merits of a variety of population-focussed interventions. These include the importance of issuing reliable information to the general public that will combat misleading information that can be so detrimental to mental health1, 2, 10, 11. One author suggests that having knowledge or perceiving oneself to have knowledge leads to increased happiness and a stronger sense of control17; another adds that good communication leads to increased trust in the Government and health authorities19. Another author comments that in order to effect behavioural change, the correct psychosocial factors must be targeted to maximise the effectiveness of interventions7.

The European College of Neuropsychopharmacology Resilience stresses the importance of building resilience at both the individual and societal levels16. Building community resilience and preparedness is the theme of several studies3, 18, 27, 43, with some authors noting that public health measures in mental health must take account of the cultural context6, 8, and that communities should be involved in addressing their own psychosocial needs15.One group warns that policy interventions themselves can have adverse effects on vulnerable populations20.

More specific public health interventions referred to in the literature include the training of additional workers, including people in the community, to deliver Psychological First Aid23, 33, 44, 45, although one author sounds a note of caution regarding the degree of training required37. Other interventions include Parent-Child Interaction Therapy36, the use of text messaging and other media30, e-health strategies31, 32, 40, 41, 48, telephone hotlines39, and the distribution of print media39, 47.

There is general consensus that a public mental health campaign should form an integral part of the overall public health response when dealing with an emergency situation21, 24, 26, 34, 38, 47 and that additional funding for mental health support and interventions should be made available to address the psychosocial problems caused or intensified by a major emergency situation22, 47.

Irish and/or International Guidance

ECDC (2017) Public health emergency preparedness – Core competencies for EU Member States[34]

While this document does not specifically deal with the psychosocial impact of a public health emergency or the interventions to address such an impact, it does address the planning and competencies required to manage an emergency. The document includes the following advice regarding communication with the public which in itself might contribute to mitigating the risk to the mental health of the general population in a public health emergency.

Emergency Risk Communication [Public]

  • Address communication inequalities. Ability to address differences across population groups on how the message is received, processed and acted upon due to the socio-economic and cultural characteristics of the population affected by the emergency.
  • Use dynamic listening and manage rumours. Ability to disseminate messages that are clear and collaborate with other organisations, including health professionals and local leaders to disseminate the message through appropriate channels and messengers.
  • Communicate risk in an accurate, transparent and timely manner. Ability to provide information to the public in a timely manner, taking into account the actual risk and the general public’s perception of the risk.
  • Foster and maintain trust. Ability to deliver messages that foster citizens’ trust in how the government handles an emergency.

International Literature

ABD-ALRAZAQ, A et al (2020) Top Concerns of Tweeters During the COVID-19 Pandemic: Infoveillance Study[35]

Background: The recent coronavirus disease (COVID-19) pandemic is taking a toll on the world’s health care infrastructure as well as the social, economic and psychological well-being of humanity. Individuals, organizations and governments are using social media to communicate with each other on a number of issues relating to the COVID-19 pandemic. Not much is known about the topics being shared on social media platforms relating to COVID-19. Analysing such information can help policy makers and health care organizations assess the needs of their stakeholders and address these needs appropriately.

Objective: This study aims to identify the main topics posted by Twitter users related to the COVID-19 pandemic.

Conclusions: Public health crisis response activities on the ground and online are becoming increasingly simultaneous and intertwined. Social media provides an opportunity to directly communicate health information to the public. Health systems should work on building national and international disease detection and surveillance systems through monitoring social media. There is also a need for a more proactive and agile public health presence on social media to combat the spread of fake news.

AVCHEN, RN et al (2019) Community Preparedness for Public Health Emergencies: Introduction and Contents of the Volume[36]

Although there are a number of definitions of community preparedness, we conceptualize it as the ability of communities to prepare for, withstand and recover from natural or human-made disasters. Community preparedness has no bounds; a crisis, whether contained at the local level or as far reaching as a pandemic, will affect diverse community populations. Preparedness planning must account for and use the multitude of complex organizational and socioeconomic components that contribute to building community resilience following a large-scale tragedy.

The articles presented in this supplement span a range of topics but just begin to touch the surface of community preparedness. Our goal with this publication is to provide a forum for advancing evidence-based practice for analysis, reflection, consideration, and potential implementation. We hope that these articles stimulate continued scientific inquiry of public health emergency preparedness and encourage future investigations focused on improving community preparedness, recovery and, ultimately, a resilient nation.

Note: The entire journal supplement samples the broad-ranging topics that comprise the body of scientific and programmatic information available on the subject. Available at https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2019.305316.

CHAO, M et al Media use and acute psychological outcomes during COVID-19 outbreak in China (2020)[37]

The COVID-19 outbreak in China led to an extraordinary threat to public health and wellbeing. This study examined the psychological impact of media use among people indirectly exposed to the disease during the initial phase of the outbreak. We conducted an internet-based survey on January 28, 2020, one week after the official declaration of person-to-person transmission of the coronavirus. Media use ¾ media forms, content of media exposure, and media engagement ¾ related to the outbreak and psychological outcomes ¾ positive and negative affect, anxiety, depression and stress ¾ of 917 Chinese adults was assessed. A series of multivariable regressions were conducted. The results showed that use of new media, rather than traditional media, was significantly associated with more negative affect, depression, anxiety and stress. Viewing stressful content was associated with more negative affect and depression. Media engagement was also associated with more negative affect, anxiety and stress. However, viewing heroic acts, speeches from experts and knowledge of the disease and prevention were associated with more positive affect and less depression. The study suggested new media use and more media engagement was associated with negative psychological outcomes, while certain media content was associated with positive psychological impact. The present study highlights the need for timely public health communication from official sources and suggests that reduced exposure to new media may be beneficial.

CHEW, QH et al (2020) Narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: practical considerations for the COVID-19 pandemic[38]

Introduction: Emerging infectious disease outbreaks such as the present coronavirus disease 2019 (COVID-19) pandemic often have a psychological impact on the well-being of the general population, including survivors and caregivers. Our study aimed to synthesise extant literature regarding the combined psychological responses and coping methods used by the general population in past outbreaks.

Methods: We conducted a narrative synthesis of the published literature over the last two decades with a quality appraisal of included articles that reported both psychological responses and coping strategies within infectious disease outbreaks.

Results: A total of 144 papers were identified from the search, 24 of which were included in the review. Overall, 18 studies examined the psychosocial responses of the general population towards the severe acute respiratory syndrome epidemic, four studies focused on the Ebola epidemic and two studies covered the H1N1 outbreak. Common themes in psychological responses included anxiety/fears, depression, anger, guilt, grief and loss, post-traumatic stress, and stigmatisation, but also a greater sense of empowerment and compassion towards others. Coping strategies adopted included problem-focused coping, seeking social support, avoidance and positive appraisal of the situation.

Conclusion: Amid the range of psychosocial responses seen in past infectious disease outbreaks, practical considerations for the current COVID-19 pandemic need to focus on the individual in the context of the larger social environment, with an emphasis on raising awareness of the range of possible psychosocial responses, access to psychological help, self-care, empowering self-support groups and sustained engagement with updated, reliable information about the outbreak.

FENDT-NEWLIN, M et al (2020) Cultural adaptation framework of social interventions in mental health: Evidence-based case studies from low- and middle-income[39]

Background: Evidence-based strategies for treating mental health conditions need to be scaled up to address the mental health treatment gap in low- and middle-income countries. Most medical and psychological interventions for the treatment of mental health conditions have been developed and evaluated in high-income countries. However, the imperative of scaling up such interventions potentially ignores local realities and may also discredit or replace local frameworks for responding to distress.

Aims: This article aims to develop a framework for the cultural adaptation of social interventions which are developed within and draw upon local contexts to ensure they are acceptable, feasible and effective.

Method: A case study approach is used to discuss the feasibility of developing and adapting psychosocial interventions which are embedded in local knowledge, values and practices.

Results: The first case study introduces yoga as an alternative and/or complementary and culturally relevant approach for people experiencing mental health conditions in India. The second case study is a cross-cultural adaptation of a psychosocial intervention to fit the local idioms of distress and service context in Sierra Leone, as the country battled with the Ebola outbreak. We use these case studies to develop a Cultural Adaptation Framework which recognises that people and their mental health are products of their culture and society to inform the future development, adaptation and evaluation of sociocultural interventions for people experiencing mental health conditions in low- and middle-income countries.

Conclusion:The Cultural Adaptation Framework can be used to ensure interventions are culturally relevant and responsive to local conditions prior to evaluating in experimental studies.

GAMMA, AE et al (2019) The impact of various promotional activities on Ebola prevention behaviors and psychosocial factors predicting Ebola prevention behaviors in the Gambia evaluation of Ebola prevention promotions[40]

The outbreak of the Ebola virus disease (EVD) from 2014 to 2016 is over. However, several outbreaks of contagious diseases have already arisen and will recur. This paper aims to evaluate the effectiveness of EVD prevention promotions in the Gambia and to assess the psychosocial factors that steer three behaviors: handwashing with soap, calling the Ebola Hotline, and not touching a person who might be suffering from EVD. In 2015, data were gathered from 498 primary care providers. The questionnaire was based on psychosocial factors from the risks, attitudes, norms, abilities, and self-regulation (RANAS) model. Three promotional activities were significantly associated with psychosocial factors of handwashing and, thus, with increased handwashing behavior: the home visit; posters; and info sheets. Norm factors ¾ especially the perception of what other people do ¾ had a great impact on handwashing with soap and on calling the Ebola Hotline. The perceived certainty that a behavior will prevent a disease was a predictor for all three protection behaviors. Commitment to the behavior emerged as especially relevant for the intention to call the Ebola Hotline and for not touching a person who might be suffering from EVD. Health behavior change programs should rely on evidence to target the right psychosocial factors and to maximize their effects on prevention behaviors, especially in emergency contexts.

GREENE, G et al (2014) Differing community responses to similar public health threats: a cross-disciplinary systematic literature[41]

Background: The way in which different communities respond to similar threats to their health can vary from outrage to indifference and public health agencies are often taken by surprise leading to potential loss of public confidence. The objective of this systematic literature review was to seek to better understand the community-level drivers that might explain the variability in response.

Methods: A vigorous systematic cross-disciplinary literature review was undertaken searching thirteen bibliographic databases and screening a variety of grey literature sources. The social amplification of risk framework and the risk perception management theoretical models were used to assess evidence and data were synthesised by narrative review.

Findings: 16 studies meeting the agreed inclusion criteria described eleven different threats ranging from infectious disease outbreaks to environmental disasters to cancer clusters affecting two or more communities were identified from medical, psychological, social science and environmental science literature. There was wide heterogeneity between the type and quality of the studies. There was a general absence of theoretical models underpinning community responses. Most studies did not report sufficient data to allow an appropriate amount of validity. Very low response rates in particular were common. Potential explanatory drivers included prior experience and visibility of threat; sociodemographic characteristics; volume and type of media coverage; government reaction; and availability of social support.

Conclusions: This review confirmed that there are significant differences. Further work is needed to develop theoretical models that apply to the community level and do not assume that a community’s response is simply the aggregate of individual level responses.

IMRAN, N et al (2020) Mental health considerations for children & adolescents in COVID-19 Pandemic[42]

Children are not indifferent to the significant psychological impact of the COVID-19 pandemic. They experience fears; uncertainties; substantial changes to their routines; physical and social isolation; and high level of parental stress. Understanding their emotions and responses is essential to properly address their needs during the pandemic. In this article, we highlight children’s vulnerability, provide an overview of common symptoms of distress in different age groups, and summarize the interventions and resources available to promote child mental health and wellbeing during these challenging times. We advocate that prioritizing mental health including child and adolescent mental health is an essential component of any universal, community-led response to COVID-19.

Crises such as the global pandemic of COVID-19 elicit a range of responses from individuals and societies adversely affecting physical and emotional wellbeing. This article provides an overview of factors elicited in response to COVID-19 and their impact on immunity, physical health, mental health and wellbeing. Certain groups such as individuals with mental illness are especially vulnerable, so it is important to maximise the supports available to this population and their families during the pandemic. More broadly, the World Health Organization recommends Psychological First Aid as a useful technique that can help many people in a time of crisis.

MUKHTAR, S (2020) Psychological health during the coronavirus disease 2019 pandemic outbreak[43]

During any community crisis, people seek out event-related information to attain the illusion of control and to exude fear of the unknown which leads to higher anxiety, and in the case of misleading misinformation and disinformation on social media, distorted perception of risk, extreme fear of the unknown and public panic. Although studies on COVID-19 are scarce, several authors have predicted the possible repercussions on psychological and physiological health not only on the vulnerable but also on the general population. Psychological interventions and psychosocial support would improve the public mental health during the COVID-19 pandemic.

Substantial evidence from past studies of epidemics on the impact of psychological health has shown psychosocial consequences in the affected individuals and in the general population. The emerging global mental health issues relative to COVID-19 pandemic may evolve into long-lasting health problems permeated through feelings of vulnerability, isolation/quarantine, fear, anxiety, psychological distress, psychosocial stressors, posttraumatic symptoms, stigma and xenophobia. It is vital to safeguard the psychological health and well-being of the population through proactive psychological interventions during the COVID-19 pandemic.

O’MALLEY, P et al (2009) Transparency during public health emergencies: from rhetoric to reality[44]

Effective management of public health emergencies demands open and transparent public communication. The rationale for transparency has public health, strategic and ethical dimensions. Still, government authorities often fail to demonstrate transparency. A key step in bridging the gap between rhetoric and reality is to define and codify transparency to put in place practical mechanisms to encourage open public health communication for emergencies. The authors demonstrate this approach using the example of the development and implementation process of a public health emergency information policy.

There are ethical, strategic and public health imperatives that point to the need for transparency in communication of information during a public health emergency. The strategic communication of information is a fundamental public health emergency management tool and needs to be recognized as such. At the same time, it acknowledges that, in practice, global public heath also often fails to match reality with rhetoric and that practical new steps are required to address such failings. Although not in itself a guarantee of transparency, the development of a public health emergency information policy by responsible authorities is a practical step that may help governments to fulfil their responsibilities during public health emergencies.

SHAH, K et al (2020) Focus on Mental Health During the Coronavirus (COVID-19) Pandemic: Applying Learnings from the Past Outbreaks[45]

Substantial evidence from the past studies of the impact of SARS, MERS, influenza and Ebola epidemics on the at-risk population, the suffering individuals and healthcare providers showed neuropsychiatric linkage. The results are relative to the current COVID-19 pandemic; they infiltrate fear, anxiety, emotional distress and post-trauma stress symptoms as the affected individuals are viewed as a minority and secluded from the rest of the population. The intervention measures that are employed by various health authorities and government bodies in combating the infection may help in eliminating the threat during the time of uncertainty; however, multivariate studies conducted on previous outbreaks show that they have long-term cognitive and mental health effects on the population. It is vital to emphasize the mental health well-being of the population and take proactive steps to minimize its detrimental effects during the COVID-19 pandemic.

SPRANG, G et al (2013) Posttraumatic stress disorder in parents and youth after health-related disasters[46]

Objectives: This study investigated the psychosocial responses of children and their parents to pandemic disasters, specifically measuring traumatic stress responses in children and parents with varying disease-containment experiences.

Methods: A mixed-method approach using survey, focus groups and interviews produced data from 398 parents. Adult respondents completed the University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index (PTSD-RI) Parent Version and the PTSD Check List Civilian Version (PCL-C).

Results: Disease-containment measures such as quarantine and isolation can be traumatizing to a significant portion of children and parents. Criteria for PTSD was met in 30% of isolated or quarantined children based on parental reports, and 25% of quarantined or isolated parents based on self-reports.

Conclusions: These findings indicate that pandemic disasters and subsequent disease-containment responses may create a condition that families and children find traumatic. Because pandemic disasters are unique and do not include congregate sites for prolonged support and recovery, they require specific response strategies to ensure the behavioral health needs of children and families. Pandemic planning must address these needs and disease-containment measures.

TAYLOR, S et al (2020) COVID stress syndrome: Concept, structure, and correlates[47]

Background: Research shows that the COVID Stress Scales have a robust multifactorial structure, representing five correlated facets of COVID-19-related distress: (a) fear of the dangerousness of COVID-19, which includes fear of coming into contact with fomites potentially contaminated with SARSCoV2; (b) worry about socioeconomic costs of COVID-19 such as worry about personal finances and disruption in the supply chain; (c) xenophobic fears that foreigners are spreading SARSCoV2; (d) traumatic stress symptoms associated with direct or vicarious traumatic exposure to COVID-19 such as nightmares or intrusive thoughts or images related to COVID-19; and (e) COVID-19-related compulsive checking and reassurance seeking. These factors cohere to form a COVID stress syndrome, which we sought to further delineate in the present study.

Methods: A population-representative sample of 6,854 American and Canadian adults completed a self-report survey comprising questions about current mental health and COVID-19-related experiences, distress and coping.

Results: Network analysis revealed that worry about the dangerousness of COVID-19 is the central feature of the syndrome. Latent class analysis indicated that the syndrome is quasi-dimensional, comprising five classes differing in syndrome severity. Sixteen percent of participants were in the most severe class and possibly required mental health services. Syndrome severity was correlated with pre-existing psychopathology and with excessive COVID-19-related avoidance, panic buying and coping difficulties during self-isolation.

Conclusion: The findings provide new information about the structure and correlates of COVID stress syndrome. Further research is needed to determine whether the syndrome will abate once the pandemic has passed or whether, for some individuals, it becomes a chronic condition.

VAN BORTEL, T et al (2016) Psychosocial effects of an Ebola outbreak at individual, community and international levels[48]

The 2013-2016 Ebola outbreak in Guinea, Liberia and Sierra Leone was the worst in history with over 28,000 cases and 11,000 deaths. Here we examine the psychosocial consequences of the epidemic. Ebola is a traumatic illness both in terms of symptom severity and mortality rates. Those affected are likely to experience psychological effects due to the traumatic course of the infection, fear of death and experience of witnessing others dying. Survivors can also experience psychosocial consequences due to feelings of shame or guilt and stigmatization or blame from their communities. At the community level, a cyclical pattern of fear occurs resulting in disruptions of community interactions and community breakdown. Health systems in affected countries were severely disrupted and overstretched by the outbreak and capacities significantly reduced as almost 900 health workers were infected with Ebola and more than 500 died. The outbreak resulted in an increased need for health services, reduced quality of life and economic productivity and social system breakdown. It is essential that the global response to the outbreak considers both acute and long-term psychosocial needs of individuals and communities. Response efforts should involve communities to address psychosocial need, to rebuild health systems and trust, and to limit stigma. The severity of this epidemic and its long-lasting repercussions should spur investment in and development of health systems.

VINKERS, CH et al (2020) Stress resilience during the coronavirus pandemic[49]

The epidemic of the 2019 novel coronavirus SARS-CoV-2 is a global public health emergency with multifaceted severe consequences for people’s lives and their mental health. In this article, as members of the European College of Neuropsychopharmacology (ECNP) Resilience, we will discuss the urgent need for a focus on resilience during the current coronavirus pandemic. We will discuss the importance of resilience at the individual and societal level, but also the implication for patients with a psychiatric condition and health care workers. We not only advocate for an increased focus on mental health during the coronavirus pandemic but also highlight the urgent need of augmenting our focus on resilience and on strategies to enhance resilience.

YANG, H et al (2020) How an Epidemic Outbreak Impacts Happiness: Factors that Worsen (vs. Protect) Emotional Well-being during the Coronavirus Pandemic[50]

What are the factors that worsen as opposed to protect emotional well-being during a pandemic outbreak such as COVID-19? Through two large-scale nationwide surveys [N1 = 11,131; N2 = 3,000] conducted in China immediately before and during the coronavirus outbreak, we found that the onset of the coronavirus epidemic led to a 74% drop in overall emotional well-being. Factors associated with the likelihood of contracting the disease such as residing near the epicenter, extent of potential harm such as age and relational issues exacerbated the detrimental effect of the outbreak on emotional well-being. Higher perceived knowledge about SARS-CoV-2 was associated with a stronger sense of control, which mediated the differences in emotional well-being. These patterns persisted even after controlling for a host of demographic and economic variables.

General overview of public mental health interventions

BANERJEE, D et al (2020) Handling the COVID-19 pandemic: Proposing a community based toolkit for psycho-social management and preparedness[51]

The psychological and economic consequences of biological disasters have been shown to outlast the infection itself. As the therapeutic focus is mainly restricted to biological therapies worldwide to develop an effective cure for the virus, the deep-rooted psycho-social repercussions are often neglected. The widespread lockdown, uncertainty of the infection, prevalent misinformation on the media and lack of a definitive cure are driving mass-hysteria, anxiety, fear and stigmatization. Research on pandemic protocols in the past have shown the role of psycho-social preparedness in improving the resilience during a ‘biological disaster’ like such large-scale infections. Though there are well-known international guidelines for disaster management in general, specific ones guided to pandemic-preparedness are lacking, though some countries have formulated their own policies. Psychological preparedness for COVID-19 has shown to affect the response and spread, based on perspectives from India. Effectiveness, applicability and feasibility are attributes which indicate that the psychosocial interventions are going to be more appropriate in the community as the knowledge, attitude and practice regarding any new infection improves the preparedness in both the health-care professionals and the general public.

HO, CS et al (2020) Mental Health Strategies to Combat the Psychological Impact of COVID-19 Beyond Paranoia and Panic[52]

To minimise the detrimental impact of misinformation that is so rampant in social media, the government and health authorities must relay to the public timely and accurate evidence-based information on the pandemic through traditional and new media. Practical tips on how the public should react during the outbreak such as the practice of good hygiene and managing fear and uncertainty of the virus through positive reframing, stress management and relaxation techniques can be disseminated to the public through video clips and cartoons that can be easily understood. Higher levels of satisfaction with existing health information have been found to correlate with lower psychological distress in individuals. Accurate and updated information on the number of recovered cases, the availability of treatments such as medicines or vaccines and regular updates on the number of infected cases and localities such as real-time or virtual maps are associated with lower stress and anxiety. With growing confidence in the measures introduced by the authorities, there is better adherence to precautionary and preventive measures that will encourage the wider community to work together to combat the outbreak.

The COVID-19 pandemic has highlighted the fragility of mental resilience and the need to have a nationwide psychological intervention plan. We have suggested 6 strategies that local and overseas authorities could consider. After their psychological defence is bolstered, countries will be equipped to succeed in their battle against COVID-19 and secure their future.

GLOVER, RE et al (2020) A framework for identifying and mitigating the equity harms of COVID-19 policy interventions[53]

We developed a conceptual framework to identify and categorise adverse effects of COVID-19 lockdown measures. We based our framework on Lorenc and Oliver’s framework for the adverse effects of public health interventions and the PROGRESS-Plus equity framework. To test its application, we purposively sampled COVID-19 policy examples from around the world and evaluated them for the potential physical, psychological and social harms, as well as opportunity costs, in each of the PROGRESS-Plus equity domains: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus [age and disability].

We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example in every PROGRESS-Plus equity domain. We identified known policy interventions intended to mitigate some of these adverse effects. The same harms [anxiety; depression; food insecurity; loneliness; stigma; violence] appear to be repeated across many groups, and are exacerbated by several COVID-19 policy interventions.

Our conceptual framework highlights the fact that COVID-19 policy interventions can generate or exacerbate interactive and multiplicative equity harms. Applying this framework can help in three ways: 1. identifying areas where a policy intervention may generate inequitable adverse effects; 2. mitigating policy and practice interventions by facilitating the systematic examination of relevant evidence; and 3. planning for lifting COVID-19 lockdowns and policy interventions around the world.

GRIFFIN, G (2020) Defining trauma and a trauma-informed COVID-19 response[54]

The framework set out by the Substance Abuse and Mental Health Services Administration (SAMHSA) allows each system to develop its definition of trauma, addressing each of the required factors in its definition and incorporating certain principles into its trauma-informed system. Trauma is defined by the presence of three factors: events, experiences, and effects. The event is the objective adverse incident that produced toxic stress. COVID-19 has the unique property of having occurred worldwide and, thus, most of the population meets the event criteria. The experience describes one’s subjective response to the adverse event.

Once a system has defined the trauma it wants to address, that system can develop its trauma-informed COVID-19 approach. SAMHSA offers key principles and tasks to accomplish when developing a trauma-informed system. These principles include safety, support and cultural sensitivity incorporated into the tasks of trauma training; screening and assessment; treatment; and avoiding re-traumatization. For example, SAMHSA’s National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit (2020) incorporates these trauma principles into a government’s behavioral health crisis response system. In addressing the pandemic and its aftermath, a government could take a similar trauma-informed approach, expanding its scope to address the entire public health system. Each system will implement its trauma-informed approach using different resources, but each system can stay consistent to its own definition of trauma in accomplishing these trauma-informed principles and tasks.

As governments transition out of shelter-in-place orders, it is time to address the ongoing trauma and grief caused by the pandemic. The ubiquitous exposure to COVID-19 argues for systems to use a trauma-informed response as a universal precaution with the goal of promoting the recovery and resilience of their residents. That starts with defining what a system means by trauma and then incorporating the appropriate trauma-informed principles and tasks into its response.

MAHOMED, F (2020) Addressing the Problem of Severe Underinvestment in Mental Health and Well-Being from a Human Rights Perspective[55]

This moment represents a truly singular opportunity for advocates and policy makers. The momentum that is building around mental health can be an unparalleled catalyst for change. In addressing the barriers to mental health and well-being, a focus on social, economic, political and legal factors can be substantially helpful. Recognition of the mental health implications of the COVID-19 pandemic demonstrates a need for investment in holistic approaches to well-being if these implications are to be effectively addressed; and funding for mental health and well-being should not be rendered secondary to other funding requirements if the right to the highest attainable standard of physical and mental health is to be realized. In keeping with the principle of participation as enshrined in the Convention of the Rights of Persons with Disabilities, the voices of those affected must be centralized in policymaking and resource allocation decisions. Addressing the various biological, social, economic, cultural and political determinants of mental health and well-being admittedly requires substantial investment, beyond even the increases that are already being seen. Still, it is clear that there is both an obligation and a need for increased attention and increased funding for the promotion and protection of mental health. Perhaps more pointedly, there is an urgent need for attention and resourcing for the promotion and protection of well-being.

MCCABE, O L et al (2014) Building a national model of public mental health preparedness and community resilience: validation of a dual-intervention, systems-based approach[56]

Objective: Working within a series of partnerships among an academic health centre, local health departments (LHDs), and faith-based organizations (FBOs), we validated companion interventions to address community mental health planning and response challenges in public health emergency preparedness.

Methods: We implemented the project within the framework of an enhanced logic model and employed a multi-cohort, pre-test/post-test design to assess the outcomes of 1-day workshops in psychological first aid (PFA) and guided preparedness planning (GPP). The workshops were delivered to urban and rural communities in Eastern and Mid-Western regions of the United States. Intervention effectiveness was based on changes in relevant knowledge, skills, and attitudes (KSAs) and on several behavioural indexes.

Results: Significant improvements were observed in self-reported and objectively measured KSAs across all cohorts. Additionally, GPP teams proved capable of producing quality drafts of basic community disaster plans in 1 day, and PFA trainees confirmed upon follow-up that their training proved useful in real-world trauma contexts. We documented examples of policy and practice changes at the levels of local and state health departments.

Conclusions: Given appropriate guidance, LHDs and FBOs can implement an effective and potentially scalable model for promoting disaster mental health preparedness and community resilience, with implications for positive translational impact.

MOHAMMED, A et al (2015) Mental health in emergency response: lessons from Ebola[57]

At-risk countries need to have intervention strategies that integrate mental health in the response to infectious disease outbreaks. These can be divided into three broad categories: before, during and after the outbreak.

After control of the outbreak, mental health services should be prepared to manage the substantial increase in need for psychological support. In some cases, this may be an opportunity to build back better: emergencies present opportunities to build stronger services.

The mental health and psychosocial response should be assessed as part of the overall review of the response. A mental health professional should be part of the team reviewing the emergency preparedness plan after the outbreak.

PATEL, V (2020) Empowering global mental health in the time of COVID19[58]

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 hair-raising 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 ¾ eg failing to communicate that the median age of death was in the mid-70 s; or acknowledging the data demonstrating that 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 ¾ without any nuancing about what those numbers actually mean ¾ served to confirm in people’s minds that the virus was inexorably sweeping the world. 

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 ¾ from psychiatric associations and global mental health practitioners to civil society advocates ¾ to unite with one message, that the pandemic and its socio-economic consequences will have profound effects on population mental health and that some of the financial resources being pumped into the COVID-19 response must be allocated to build back better mental health care systems in all countries.

PFEFFERBAUM, B et al (2012) The H1N1 crisis: a case study of the integration of mental and behavioral health in public health crises[59]

In substantial numbers of affected populations, disasters adversely affect well-being and influence the development of emotional problems and dysfunctional behaviors. Nowhere is the integration of mental and behavioral health into broader public health and medical preparedness and response activities more crucial than in disasters such as the 2009-2010 H1N1 influenza pandemic. The National Biodefense Science Board, recognizing that the mental and behavioral health responses to H1N1 were vital to preserving safety and health for the country, requested that the Disaster Mental Health Subcommittee recommend actions for public health officials to prevent and mitigate adverse behavioral health outcomes during the H1N1 pandemic. The subcommittee’s recommendations emphasized vulnerable populations and concentrated on interventions, education and training, and communication and messaging. The subcommittee’s H1N1 activities and recommendations provide an approach and template for identifying and addressing future efforts related to newly emerging public health and medical emergencies. The many emotional and behavioral health implications of the crisis and the importance of psychological factors in determining the behavior of members of the public argue for a programmatic integration of behavioral health and science expertise in a comprehensive public health response.

PLOUGH, A et al (2013) Building community disaster resilience: perspectives from a large urban county department of public health[60]

An emerging approach to public health emergency preparedness and response, community resilience encompasses individual preparedness as well as establishing a supportive social context in communities to withstand and recover from disasters. We examine why building community resilience has become a key component of national policy across multiple federal agencies and discuss the core principles embodied in community resilience theory ¾ specifically, the focus on incorporating equity and social justice considerations in preparedness planning and response. We also examine the challenges of integrating community resilience with traditional public health practices and the importance of developing metrics for evaluation and strategic planning purposes. Using the example of the Los Angeles County Community Disaster Resilience Project, we discuss our experience and perspective from a large urban county to better understand how to implement a community resilience framework in public health practice.

SHREYASWI S M et al (2020) Stigma reduction and provision of mental health services in the public health response to COVID-19[61]

Stigma reduction and provision of mental health services are unique challenges associated with the new COVID 19 pandemic. Stigma and discrimination may affect the patients diagnosed with COVID 19, those who have been placed under quarantine as well as the frontline. Effective, accurate and timely communication delivered in a coordinated manner along with community engagement is the cornerstone for stigma reduction and promotion of mental health. Although several steps have been taken to address stigma and promote mental health, it is imperative that a clearly defined strategy be put in place to integrate mental health services into the public health response to COVID 19.

WEINE, S et al (2020) How can the COVID-19 response advance global mental health?[62]

Global Mental Health aims to address mental health challenges in the context of socio-economic adversity, social suffering and limited existing resources, primarily in Low and Middle Income Countries (LMICs). Global Mental Health integrates mental health into primary care, provides affordable and effective community-based care and strengthens the mental health training of all healthcare personnel. Task sharing ¾ a key Global Mental Health strategy ¾ trains laypersons and mid-level professionals to provide mental health services. This is distinct from the specialist-based practice models which dominate mental health care in high-income countries for those who can afford to pay.
The challenge for Global Mental Health is to draw upon these strategies and push the field even further to respond to the mental health consequences of COVID-19. At least three growth opportunities are evident. The first growth opportunity is using a public health framework to respond to the mental health consequences of the pandemic. COVID-19 has resulted in widespread fear and worry in general populations across the globe. Evidence from prior disasters suggests that such mental health distress will likely continue for many as the pandemic evolves and even remits, especially among vulnerable populations. A public health approach prioritises the development of interventions that can reach far more people than clinical strategies; it can inform building models of primary prevention involving low-cost, low-intensity interventions that promote mental health literacy and self-management and secondary prevention which integrates mental health care into medical settings through collaborative care models.

Interventions

AGYAPONG, VIO (2020) Coronavirus Disease 2019 Pandemic: Health System and Community Response to a Text Message (Text4Hope) Program Supporting Mental Health in Alberta[63]

Alberta’s Chief Medical Officer launched a free supportive text message service ¾ Text4Hope ¾ on behalf of Alberta Health Services. Text4Hope allows subscribers to receive 3 months of daily supportive text messages with or without links to online mental health resources. Individuals can subscribe to Text4Hope by simply texting “COVID19HOPE” to a short code number. The messages were crafted by a team of clinical psychologists, psychiatrists, mental health therapists and mental health patients to address stress, anxiety and depression. An example of the messages sent is: “When bad things happen that we can’t control, we often focus on the things we can’t change. Focus on what you can control; what you can do to help yourself or someone else today.” The Text4Hope program was modeled after the Text4Mood program, which was launched in Northern Alberta in 2016 and played a vital role in supporting the mental health of residents of Fort McMurray during the wildfires of the same year. Text4Mood was subsequently recognized as a mental health innovation by the Mental Health Innovations Network, which is headquartered at the Department of Mental Health and Substance Abuse of the WHO.

Since the launch of the program, there have been interests in launching similar programs in other jurisdictions in Canada, Australia and Ghana. The massive subscription to the supportive text messaging program in Alberta suggests that such a service is feasible and acceptable to end-users, and can potentially support the mental health of people in self-isolation, quarantine or lockdown during pandemics and other emergencies in Canada and around the world.

BÄUERLE, A et al (2020) An e-mental health intervention to support burdened people in times of the COVID-19 pandemic: CoPE It[64]

The developed e-mental health intervention CoPE It offers manualized, evidence-based psychotherapeutic/psychological support to overcome psychological distress in times of COVID-19; e-mental health approaches offer great possibilities to support burdened people during the SARS-CoV-2 pandemic effectively. CoPE It is a self-guided e-mental health intervention for burdened people in times of COVID-19 to overcome psychological distress and improve mental health. The CoPE It intervention is based on the established, evidence-based psychotherapeutic/psychological intervention techniques of mindfulness-based stress reduction and cognitive behavioral therapy and has been adapted to the context of the corona pandemic by experts for psychosomatic medicine and stress prevention from the universities of Duisburg-Essen and Tübingen. CoPE It is a self-guided e-mental health intervention for burdened people in times of COVID-19 to overcome psychological distress and improve mental health. The CoPE It intervention is based on the established, evidence-based psychotherapeutic/psychological intervention techniques of mindfulness-based stress reduction and cognitive behavioral therapy and has been adapted to the context of the corona pandemic by experts for psychosomatic medicine and stress prevention from the universities of Duisburg-Essen and Tübingen.

BENNETT, CB et al (2020) eHealth to redress psychotherapy access barriers both new and old: A review of reviews and meta-analyses[65]

This review of reviews and meta-analyses outlines the strength of evidence and effect sizes for guided and unguided approaches to eHealth interventions targeting common problems in psychotherapy: depression, anxiety, substance abuse and general well-being. After a comprehensive search, a total of 65 reviews and meta-analyses were identified and evaluated for treatment effects, moderators, acceptability and attrition. Findings show eHealth is acceptable and effective at improving depression, anxiety, alcohol-related problems and general mental health compared to waitlist, and may even offer benefit as an adjunct to traditional psychotherapy. Mixed evidence was found when comparing guided versus unguided interventions as well as the strength of benefit relative to active controls and the degree to which these approaches are associated with attrition. eHealth interventions have the potential to be an effective tool for redressing both new and old psychotherapy access barriers.

CÉNAT, JM et al (2020) ‘A systematic review of mental health programs among populations affected by the Ebola virus disease[66]

This review identified eleven MHPSS programs in Sierra Leone, Liberia, Guinea and the DRC. Some programs have been implemented in more than one country. Two reports identified among the publications were evaluated. The start dates of these programs were between 2014 and 2018. The vast majority of programs were funded by international organizations. Although program activities varied, five programs incorporated concepts of Psychological First Aid (PFA). The aim of PFA is to offer immediate support to individuals following exposure to a crisis event by offering non-intrusive practical care and support. We also included a study evaluating the effectiveness of short PFA-based programs following EVD outbreaks.

DONG, L et al (2020) Public Mental Health Crisis during COVID-19 Pandemic, China[67]

The National Health Commission of China released a notification on January 26, 2020, providing guiding principles of the emergency psychological crisis interventions to reduce the psychosocial effects of the COVID-19 outbreak. This notification specified that psychological crisis intervention should be part of the public health response to the COVID-19 outbreak, organized by the joint prevention and control mechanism at city, municipal and provincial levels, and that the interventions should be differentiated by group. The intervention workforce comprises psychological outreach teams led by psychiatrists and mental health professionals and psychological support hotline teams. An attachment to this notification further outlined the key intervention targets for 6 groups: confirmed patients, persons under investigation for COVID-19, healthcare workers, persons in immediate contact with patients, ill persons who refuse to seek care, and susceptible persons among the general public. The release of such policy guidance acknowledges China’s recognition of public mental health needs during the outbreak. However, the notification does not specify how different resources should be mobilized and coordinated or, more important, who should deliver which type of interventions, for which group in need, and by which delivery mode(s). The policy guidance also does not indicate operationalization of how various groups should be screened or assessed to determine the type and level of interventions to provide to each. This level of detail is needed because China lacks a well-established mental healthcare system and has no existing national-level emergency response system and designated workforce to provide the psychological crisis interventions during a national emergency or disaster. Other major challenges to successfully implementing the emergency psychological crisis interventions include China’s severe shortage of mental health providers. The challenges reported in China indicate that for many developing countries telemedicine should be considered to help remove barriers to accessing quality care for mental health. Task-shifting or -sharing ¾ shifting service delivery of specific tasks from professionals to persons with fewer qualifications; or creating a new cohort of trained providers ¾ might help, especially in low-resource areas. Countries should also consider requesting support and guidance from global mental health authorities and research communities through international collaborations.

Mindful of lessons learned from past outbreaks in China and other parts of the world, public mental health interventions should be formally integrated into public health preparedness and emergency response plans to effectively curb all outbreaks.

DUCKERS M L A et al (2018) Measuring and modelling the quality of 40 post-disaster mental health and psychosocial support programmes[68]

Disasters can have an enormous impact on the health and well-being of those affected. Internationally, governments and service providers are often challenged to address complex psychosocial problems. Ideally, the potentially broad range of support activities include a coherent, high-quality mental health and psychosocial support (MHPSS) programme. We present a theory-driven quantitative analysis of the quality of 40 MHPSS programmes, mostly implemented in European disaster settings. The objective is to measure quality domains recognized as relevant in the literature and to empirically test associations. During the EU project Operationalizing Psychosocial Support in Crisis (OPSIC) an evaluation survey was designed and developed for this purpose and completed by 40 MHPSS programme coordinators involved in different mass emergencies and disasters. We analysed the survey data in two steps. Firstly, we used the data to operationalize quality domains of a MHPSS programme, tested constructs and assessed their internal consistency reliability. A total of 26 out of 44 survey items clustered into three of the four domains identified within the theoretical framework: planning and delivery systems; general evaluation criteria; and essential psychosocial principles. Measures and interventions comprised a potential fourth domain, but could not be confirmed to empirically cluster together. Secondly, several models with associations between domains and measures and interventions were tested and compared. The model with the best fit suggests that in MHPSS programmes with higher planning and delivery systems score a larger number of measures and interventions when evidence-informed guidelines are applied. In such programmes, coordinators are more positive about general evaluation criteria and the realization of essential psychosocial principles. Moreover, the analyses showed that some measures and interventions are more likely to be applied in programmes with more evolved planning and delivery systems, yet for most measures and interventions the likelihood of being applied is not linked to planning and delivery system status, nor to coordinator perceptions concerning psychosocial principles and evaluation criteria. Further research is necessary to validate and expand the findings and to learn more about success factors and obstacles for MHPSS programme implementation.

GURWITCH, RH et al (2020) Leveraging parent-child interaction therapy and telehealth capacities to address the unique needs of young children during the COVID-19 public health crisis[69]

Parent–Child Interaction Therapy (PCIT), a short-term, evidence-based treatment designed for families with young children experiencing behavioral and/or emotional difficulties is particularly well-positioned to address some of the most pressing child and parental needs that arise during stressful times. Telehealth formats of PCIT, such as Internet-delivered PCIT (iPCIT), have already been supported in controlled trials. This commentary explores PCIT implementation during the COVID-19 public health crisis and the challenges encountered in the move toward Internet-delivered services.

One challenge in adopting PCIT via telehealth pertains to reimbursement issues; another challenge is the variability among families and therapists with regard to technological literacy, facility, trust and capacity. During the COVID-19 crisis, many school districts distributed tablets to families of limited means, and many telecommunications companies provided free broadband, making online learning more equitable in the United States. For therapists’ transition to telehealth, iPCIT experts developed materials, webinars and videos to aid in therapists’ confidence and abilities to provide iPCIT effectively.

In conclusion, PCIT is a long-established and flexible treatment showing strong effectiveness in reducing child behavior problems, containing child trauma symptoms, decreasing physical punishment and maltreatment, lowering caregiver stress and depression, fostering positivity in family relations, and promoting more secure parent–child attachments. Augmenting standard PCIT with PFA and leveraging modern technologies to afford synchronous but remote care is already addressing the urgent mental health needs of many families with young children during this uniquely stressful and challenging time. However, in order to achieve a meaningful public health impact during the COVID-19 pandemic and its aftermath, large-scale dissemination and implementation efforts are now needed, along with permanent changes in telehealth policy.

HORN, R et al (2019) The myth of the 1-day training: the effectiveness of psychosocial support capacity-building during the Ebola outbreak in West Africa[70]

This paper considers the effectiveness of short training programmes to equip volunteers to provide psychosocial support in emergencies, focusing particularly on whether the PFA training provided during the Ebola outbreak enabled non-specialists to incorporate the key principles into their practice. Findings indicate that many PFA training-of-trainers were short and rarely included content designed to develop training skills. As a result, the PFA training delivered was of variable quality. PFA providers had a good understanding of active listening, but responses to a person in distress were less consistent with the guidance in the PFA training or with the principles of effective interventions outlined by Hobfoll et al. There are advantages to training non-specialists to provide psychosocial support during emergencies, and PFA has all the elements of an effective approach. However, the very short training programmes which have been used to train non-specialists in PFA might be appropriate for participants who already bring a set of relevant skills to the training, but for others it is insufficient. Government/NGO standardisation of PFA training and integration in national emergency response structures and systems could strengthen in-country capacity.

HIJUN, J et al (2020) Psychosocial Support during the COVID-19 Outbreak in Korea: Activities of Multidisciplinary Mental Health Professionals[71]

As of April 18, 2020, there have been a total of 10,653 confirmed cases and 232 deaths due to coronavirus disease 2019 (COVID-19) in Korea. The pathogen spread quickly, and the outbreak caused nationwide anxiety and shock. This study presented the anecdotal records that provided a detailed process of the multidisciplinary teamwork in mental health during the COVID-19 outbreak in the country. Psychosocial support is no less important than infection control during an epidemic, and collaboration and networking are at the core of disaster management. Thus, a multidisciplinary team of mental health professionals was immediately established and has collaborated effectively with its internal and external stakeholders for psychosocial support during the COVID-19 outbreak.

An academic association called the Korean Society for Traumatic Stress Studies (KSTSS) was organized in November 2015 after the Sewol ferry disaster in April 2014, as the demand for networking and collaboration of mental health professionals increased in order to deal with mental health issues in times of disasters in Korea. The members of the KSTSS consisted of diverse professionals: psychiatrists, social workers, psychologists, nurses, counselors, emergency medicine doctors, and researchers. The KSTSS has cooperated with Korean government institutions in managing disaster mental health while going through several disasters in Korea since 2015. Based on this preexisting relationship, the cooperative work between the KSTSS and Korean government institutions for disaster mental health management had initiated from the beginning of the COVID-19 outbreak in Korea. This paper described the multidisciplinary team’s activities to provide psychosocial support during the COVID-19 outbreak in Korea from January 20 to March 31, 2020. In Figure 1, major social events related to COVID-19 and psychosocial support provided by the KSTSS and Korean government institutions were described in chronological order.

JUNG, SJ (2020) Mental Health and Psychological Intervention Amid COVID-19 Outbreak: Perspectives from South Korea[72]

The Korean Neuropsychiatric Association has also published guidelines targeting five population domains: the public, parents of young children, quarantined people, medical professionals who treat COVID-19 patients, and other medical practitioners. These guidelines, released by the Ministry of Health and Welfare, suggest perceiving an anxiety response to an outbreak as normal and refraining from the act of avoiding specific groups. They also highlight the need to rely on credible information.

The National Center for Mental Health (NCMH) is offering psychological counselling for people who are quarantined in Daegu as well as those who have recently returned from Wuhan, and has released guidelines for people with symptoms of COVID-19. Similar to the Korean Neuropsychiatric Association, the NCMH is advising the public to cooperate with the quarantine authorities and build skills to relax during distress ¾ the instructions focus on individual skills and knowledge.

Moreover, the Psychological Support Group Network of the Ministry of Health and Welfare provides information on hotlines for the current mental health crisis; the response system is different for people with COVID-19 and their families versus the quarantined and general public. The National Center for Disaster Trauma, a subdivision of the NCMH, has also released leaflets warning about the possible mental health problems as well as guidelines to cope. These underline the importance of getting reliable information, maintaining social networks, expressing negative emotions, continuing daily life activities, and pursuing pleasant experiences.

In summary, amid the spread of COVID-19 in South Korea, psychological interventions are being performed in several aspects. However, a public approach is needed to overcome common psychological barriers. Two of the most common problems are the breakdown of social support structures and the stigmatization of patients. However, the current approach to mental health issues seems to focus mostly on individual factors rather than the public. Therefore, the establishment of a public system is crucial to verify the validity of information released by the media. Communities and mental health authorities should consistently make efforts to enhance social support systems and eliminate stigma of the disease. Building a targeted mental healthcare strategy for different population domains including the quarantined and medical staff would also be beneficial.

LIU, S (2020) Online mental health services in China during the COVID-19 outbreak[73]

The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak. Fast transmission of the virus between people hinders traditional face-to-face psychological interventions. By contrast, provision of online mental health services is safe. To date, several types of online mental health services have been implemented widely for those in need during the outbreak in China.

Firstly, as of Feb 8, 2020, 72 online mental health surveys associated with the COVID-19 outbreak could be searched for via the WeChat-based survey programme Questionnaire Star, which target different populations, including medical staff, patients with COVID-19, students, the general population, and mixed populations. One multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University, Guangzhou, China, found the prevalence of depression, defined as a total score of ≥5 in the Patient Health Questionnaire, to be 50·7%; of anxiety, defined as a total score of ≥5 in the Generalized Anxiety Disorder, to be 44·7%; of insomnia to be 36·1%, defined as a total score of ≥8 in the Insomnia Severity Index; and of stress-related symptoms, defined as a total score of ≥9 in the Impact of Events Scale-Revised, to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems.

Secondly, online mental health education initiatives with communication programmes such as WeChat and Weibo have been widely used during the outbreak for medical staff and the public.

In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies provided to the public. As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health.

Finally, online psychological counselling services such as WeChat-based resources have been widely established by mental health professionals in medical institutions, Universities and academic societies throughout all 31 provinces, municipalities and autonomous regions in mainland China, which provide free 24-hour services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety and insomnia have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue by monitoring and analysing messages posted on Weibo and alerting designated volunteers to act accordingly.

In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions.

O’CONNOR, K et al (2020) Mental Health Impacts of COVID-19 in Ireland and the Need for a Secondary Care, Mental Health Service Response[74]

The paper lists the Groups who will be particularly vulnerable to the emergence of new mental health difficulties requiring secondary care interventions: COVID-19 survivors; people bereaved during the pandemic; frontline workers; those with fewer social and economic resources; extremes of the population demographic; individuals with an intellectual disability; individuals who are pregnant or in the post-partum period. The authors recommend:

  • ring-fencing an additional COVID-19 budget for mental health services
  • prioritising access to smart phones, laptops and high-quality broadband which is still an issue in many areas and adapt and develop digital health interventions
  • accelerating implementation of the National Clinical Programmes in Mental Health

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.

RANSING, R (2020) Mental Health Interventions during the COVID-19 Pandemic: A Conceptual Framework by Early Career Psychiatrists[75]

The emergence of mental health problems during a pandemic is extremely common, though difficult to address due to the complexities of pandemics and the scarcity of evidence about the epidemiology of pandemic-related mental health problems and the potential interventions to tackle them. Little attention has been devoted so far to this topic from policymakers, stakeholders and researchers, resulting in a lack of replicable, scalable and applicable frameworks to help plan, develop and deliver mental health care during pandemics. As a response, we have attempted to develop a conceptual framework that could guide the development, implementation and evaluation of mental health interventions during the ongoing COVID-19 pandemic. This conceptual framework was developed by early career psychiatrists from 16 countries that cover all the WHO regions. Their opinions were elicited via a semi-structured questionnaire. They were asked to provide their views about the current mental health situation in their countries and to elaborate on existing myths and misinformation. They were also asked to name the resources available and to propose solutions and approaches to provide accessible and affordable care. The conceptual framework was prepared based on the extant literature and the views discussed in this group; it illustrates the epidemiology of mental health problems, preparedness plans, stage-specific plans or innovative solutions, opportunities to integrate those plans and possible outcomes at policy level. The conceptual framework can serve as a technical guide for future research regarding pandemics; it can be used to monitor trends and to optimize efforts, and to develop evidence based mental health interventions. Still, further research focusing on the individual components of this framework is needed.

SAUL, J et al (2016) Building Resilience in Families, Communities, and Organizations: A Training Program in Global Mental Health and Psychosocial Support[76]

This article describes the Summer Institute in Global Mental Health and Psychosocial Support, a brief immersion training program for mental health and other health professionals who work with populations that have endured severe adversities and trauma such as domestic and political violence, extreme poverty, armed conflict, epidemics and natural disasters. The course taught participants to apply collaborative and contextually sensitive approaches to enhance social connectedness and resilience in families, communities and organizations. This article presents core training principles and vignettes which illustrate how those engaging in such interventions must: 1. work in the context of a strong and supportive organization; 2. appreciate the complexity of the systems with which they are engaging; and 3. be open to the possibilities for healing and transformation. The program utilized a combination of didactic presentations, hands-on interactive exercises, case studies and experiential approaches to organizational team building and staff stress management.

SIJBRANDIJ, M et al (2020) The Effect of Psychological First Aid Training on Knowledge and Understanding about Psychosocial Support Principles: A Cluster-Randomized Controlled Trial [77]

Psychological First Aid (PFA) is a world-wide implemented approach to helping people affected by an emergency, disaster or other adverse event. Controlled evaluations of PFA’s training effects are lacking. We evaluated the effectiveness of a one-day PFA training on the acquisition and retention of knowledge of appropriate responses and skills in the acute aftermath of adversity in Peripheral Health Units (PHUs) in post-Ebola Sierra Leone. Secondary outcomes were professional quality of life, confidence in supporting a distressed person, and professional attitude. 129 PHUs in Sierra Leone were cluster-randomized across PFA [206 participants] and control [202 participants] in March 2017. Knowledge and understanding of psychosocial support principles and skills were measured with a questionnaire and two patient scenarios to which participants described helpful responses. Professional attitude, confidence and professional quality of life were assessed using self-report instruments. Assessments took place at baseline and at three- and six-months post-baseline. The PFA group had a stronger increase in PFA knowledge and understanding at the post-PFA training assessment (d = 0.50; p < 0.001) and at follow-up (d = 0.43; p = 0.001). In addition, the PFA group showed better responses to the scenarios at six-months follow-up (d = 0.38; p = 0.0002) but not at the post-assessment (d = 0.04; p = 0.26). No overall significant differences were found for professional attitude, confidence and professional quality of life. In conclusion, PFA training improved acquisition and retention of knowledge and understanding of appropriate psychosocial responses and skills in providing support to individuals exposed to acute adversity. Our data support the use of PFA trainings to strengthen capacity for psychosocial support in contexts of disaster and humanitarian crisis. Future studies should examine the effects of PFA on psychosocial outcomes for people affected.

MINIHAN, E et al (2020) COVID-19, Mental Health and Psychological First Aid[78]

Crises such as the global pandemic of COVID-19 elicit a range of responses from individuals and societies adversely affecting physical and emotional well-being. This article provides an overview of factors elicited in response to COVID-19 and their impact on immunity, physical health, mental health and wellbeing. Certain groups such as individuals with mental illness are especially vulnerable so it is important to maximise the supports available to this population and their families during the pandemic. More broadly, the World Health Organization recommends Psychological First Aid as a useful technique that can help many people in a time of crisis.

YOON, MK et al (2016) System effectiveness of detection, brief intervention and refer to treatment for the people with post-traumatic emotional distress by MERS: a case report of community-based proactive intervention in South Korea[79]

Mental health service system for MERS victims had the following two parts: a mental health service for people who had been placed in quarantine and a service provided to families of patients who had died or recovered patients. The government of Gyeonggi province, public health centers, regional and local Community Mental Health Centers and the National Center for Crisis Mental Health Management participated. Among 1221 Gyeonggi people placed in quarantine and who experienced psychological and emotional difficulties, 350 required continuing services; 124 received continuing services: ie 35 % of people who required psychological intervention received contact from service providers and received the required services.

Conclusions: this study reflects a proactive monitoring system for thousands of people placed under quarantine for the first time in Korea. It is significant that service utilization through actively approaching and contacting people rather than passively providing information was much higher than other general mental health services in Korea. The core value of public mental health services is adequate public accessibility; it is therefore essential for governments to strengthen their professional competence and establish effective systems. These criteria should also be applied to psychological problems caused by disastrous infectious disease outbreaks.

ZHOU, J et al (2020) Mental Health Response to the COVID-19 Outbreak in China[80]

On January 26, 2020, the National Health Commission of China released principles for emergency psychological crisis intervention for the COVID-19 pandemic. Mental health hotlines were quickly established across China and provided the public with counseling and psychological services. The telephone and Internet have been widely used to deliver mental health care services, and social media platforms have been used to share strategies, guidelines, and education programs for managing potential mental distress. In addition, a series of self-help handbooks for psychological care associated with COVID-19 have been published by the China Association for Mental Health, medical institutions, and universities.

ZHOU, X (2020) The Role of Telehealth in Reducing the Mental Health Burden from COVID-19[81]

Examples of and evidence to support the effectiveness of tele-mental health are fairly diverse, especially in the context of depression, anxiety and PTSD. Videoconferencing online forums, smartphone apps, text-messaging and e-mails have been shown to be useful communication methods for the delivery of mental health services.

China is actively providing various tele-mental health services during the outbreak of COVID-19. These services are from government and academic agencies and include counseling, supervision, training, as well as psychoeducation through online platforms such as hotline, WeChat, and Tencent QQ. Tele-mental health services have been prioritized for people at higher risk of exposure to COVID-19, including clinicians on the frontline, patients diagnosed with COVID-19 and their families, policemen, and security guards. Early reports also showed how people in isolation actively sought online support to address mental health needs, which demonstrated both a population interest and acceptance of this medium.

Additional telehealth services have been previously funded by the Australian Government to address mental health needs of rural and remote patients during emergency situations such as long-term drought and bushfires. In response to COVID-19, the Australian Government has responded with additional funded services through the Medicare Benefits Schedule enabling a greater range of telehealth services to be delivered, including telehealth consultations with general practitioners and specialists. However, the expanded telehealth program is restricted to special needs groups and the wider population does not have access to the program. A major benefit of expanding telehealth including mental health with no restrictions would reduce person-to-person contact between health service providers and COVID-19 and reduce the risk of exposure of non-infected but susceptible patients in waiting room areas. To date, most of the Australian Government’s focus has been on managing medical needs of people during the epidemic, rather than providing resources to meet short- and long-term mental health implications. An expansion of access to tele-mental health support services with a focused public education campaign to promote these services would begin to address this need.

Communication of all health needs is important when patients are having to be isolated. We support the use of telehealth as a valuable way of supporting both physical and psychosocial needs of all patients irrespective of geographical location. Simple communication methods such as e-mail and text messaging should be used more extensively to share information about symptoms of burnout, depression, anxiety and PTSD during COVID-19, to offer cognitive and/or relaxation skills to deal with minor symptoms, and to encourage access to online self-help programs. For people with COVID-19, telehealth can be used to monitor symptoms and also to provide support when needed.

OTHER

DURCAN, G et al (2020) COVID-19 and the nation’s mental health: Forecasting needs and risks in the UK [Centre for Mental Health][82]

The mental health impacts of COVID-19 are likely to be significant and sustained. Projecting the extent and duration of the effects on mental health is not easy. While numerous surveys among the public, health workers and people with mental health difficulties all point to a sudden marked increase in psychological distress, much of that distress will be an immediate and natural response to the current situation. For the majority of people in the UK, the stress, anxiety and isolation everyone is experiencing will be short-lived. However, it is also clear that for some groups of people the effects on mental health are more severe and will be longer lasting; and to a large extent, inequalities in mental health ¾ which reflect broader economic and social inequalities ¾ are being exacerbated during the crisis and likely to be perpetuated afterwards. For people whose livelihoods are precarious, whose physical and mental health were already poor, or whose daily lives are unsafe because of abuse and violence, the psychological impact of COVID-19 is likely to be more serious and more prolonged. We can therefore predict that the biggest mental health impacts will be felt in groups of people such as: people with existing mental health difficulties; people with long-term physical health conditions; people directly affected by COVID-19; people who experience heightened risks from being locked down at home; people on lower incomes and with precarious livelihoods; people from Black, Asian and minority ethnic communities.

While it is still early days in understanding and acting on the implications of COVID-19 for the mental health of the population, it is clear that the impact may be significant both immediately and for some time to come; it is therefore important to prepare for what is to come. Where possible, it will be important to seek to prevent poor mental health resulting from the pandemic. And where necessary, it will be essential to offer timely and effective support to people who are experiencing difficulties. For many, this will mean ensuring access to existing mental health services through routine means, while for others it may require a tailored response. At this time, we would recommend:

  1. The Government should ensure that it continues to provide a financial safety net for people whose livelihoods are affected by the pandemic to prevent further financial insecurity and the serious effects this has on people’s mental health. This should recognise that not all localities and communities will experience the same economic impacts, with more help offered to those experiencing the biggest risks.
  2. The Government and Public Health England should provide advice and support to organisations including schools, health and care services and businesses in trauma-informed approaches to help them to create a sense of psychological safety for people who use and work in them following the lockdown.
  3. The NHS should develop a proactive and tailored offer of mental health support to people who have received hospital treatment for COVID-19, to people who are working in health and care services with people with COVID-19, and to people who have experienced a bereavement during the pandemic.
  4. The NHS should prepare for both a V-shaped and a W-shaped recession during the next five years, with resources ¾ financial and human ¾ to respond to either a single, deep recession in 2020 or to a series of economic shocks each of which will create additional requirements for mental health support.

Inter-Agency Standing Committee (IASC) (2007) IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings[83]

The primary purpose of these guidelines is to enable humanitarian actors and communities to plan, establish and coordinate a set of minimum multi-sectoral responses to protect and improve people’s mental health and psychosocial well-being in the midst of an emergency. The focus of the guidelines is on implementing minimum responses: ie essential, high-priority responses that should be implemented as soon as possible in an emergency. Minimum responses are the first things that ought to be done; they are the essential first steps that lay the foundation for the more comprehensive efforts that may be needed, including during the stabilised phase and early reconstruction. To complement the focus on minimum response, the guidelines also list concrete strategies for mental health and psychosocial support to be considered mainly before and after the acute emergency phase. These ‘before’ [emergency preparedness] and ‘after’ [comprehensive response] steps establish a context for the minimum response and emphasise that the minimum response is only the starting point for more comprehensive supports. Although the guidelines have been written for low- and middle-income countries, the overall framework and many parts of the guidelines apply also to large scale emergencies in high-income countries.

Illinois rolls out COVID‐19 MH crisis hotline as cases climb (17/04/2020)[84]

After another deadly 24 hours in Illinois, Governor JB Pritzker announced a new program to connect scared and depressed Illinois residents to badly needed mental health services, Block Club Chicago reported on 11 April 2020. In the 24 hours in question, 81 people died from COVID‐19 and 1,293 new confirmed cases were reported. Hoping to help those in need of mental and physical health care during the crisis, the State has created programs that will help people from afar. Call4Calm, a free emotional support text line, was created to serve Illinois residents “swimming in the stress and uncertainty” caused by COVID‐19, Pritzker said. To connect with a counselor, people can text TALK to 552020 or text HABLAR to the same number for counseling in Spanish. Users will remain anonymous, and the state has partnered with mental health organizations to have counselors respond. Once a resident texts the hotline, they’ll get a call from a licensed counselor within 24 hours. The program was announced as the state reached 19,180 confirmed COVID‐19 cases, said Dr. Ngozi Ezike, director of the Illinois Department of Public Health.


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Produced by the members of the National Health Library and Knowledge Service Evidence Team. Current as at [27 JULY 2020].This evidence summary collates the best available evidence at the time of writing and does not replace clinical judgement or guidance. Emerging literature or subsequent developments in respect of COVID-19 may require amendment to the information or sources listed in the document. Although all reasonable care has been taken in the compilation of content, the National Health Library and Knowledge Service Evidence Team makes no representations or warranties expressed or implied as to the accuracy or suitability of the information or sources listed in the document. This evidence summary is the property of the National Health Library and Knowledge Service and subsequent re-use or distribution in whole or in part should include acknowledgement of the service.

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