#MHForAll Webinar: COVID-19 and the direct impacts on mental health
Chair
Niall Boyce, The Lancet Psychiatry
Panellists
Ed Bullmore, University of Cambridge
Maxime Taquet, University of Oxford
Nisreen Alwan, University of Southampton
John McConnell, The Lancet Infectious Diseases
This webinar series came out of a focus on the impact of COVID-19 on mental health, and for the first two sessions of this year we’ll be looking at where we are now and what we have learned. This week we’ll be discussing the impacts of the pandemic on mental health, and the next session will take a broader look at what the pandemic has meant for the provision and delivery of mental health services.
Niall Boyce
So what do we know about the direct effects of the virus on the brain?
Ed Bullmore
COVID impacts mental health in two ways: through the social response (the pandemic response, lockdown, the economic consequences etc.) which will have an impact on a population level, and through its effects on the brain which is specific to patients. We know there is an impact on the brain, for example the loss of smell and taste, and ongoing research has pointed to a higher risk of neurological and psychiatric complications for patients with acute COVID.
Niall Boyce
How do the effects of COVID-19 on mental health differ from other severe illnesses that might affect people?
Maxime Taquet
The rate of psychiatric illness after COVID is significantly higher than after many other physical illnesses. Any medical illness can potentially trigger psychiatric illness, so we need to examine the extent to which that is the case for COVID. The question is not whether COVID-19 would cause or lead to an increased rate of psychiatric illnesses, but the extent to which that is the case.
We’ve looked at a group of patients and compared the rate of psychiatric illness with other illnesses. In 3 weeks after infection just under 1 in 5 experience psychiatric illness, and 1 in 4 are diagnosed with psychiatric illness. That’s about 50% higher to twice as high as for other illnesses. This shows COVID-19 is associated with significantly more psychiatric consequences than the majority of other illnesses.
Niall Boyce
This impact is due both to the physical, direct effect of the virus on the brain, and the social effects of COVID. How do you begin to detangle these?
Maxime Taquet
We have to compare it with other illnesses which are also very serious and can be life threatening, and carry a strong stress factor, and the mental health impact these have.
Ed Bullmore
The biological response itself can be multifaceted - embolisms, the effect on blood and probability of clotting, and strokes are all examples, even in younger people who aren’t especially vulnerable. There are also effects on the brain as a result of the immune response to the infection, and we know from other studies that this can have adverse effects on the nervous system. There is also a risk that the virus gets into the brain and has a neurological impact, with post mortem studies showing evidence of direct infection of membranes around and within the brain. As a result there are multiple cognitive consequences.
Niall Boyce
What about long COVID and its impacts? How much do we know about this?
Nisreen Alwan
Long COVID is an umbrella term to describe the unexplainable. I had the infection, and most of us did not have access to testing then. The symptoms fluctuate, some stay and persist throughout, but often they change. A higher proportion of those with long COVID report cognitive symptoms later on. Definitions vary, but long COVID is generally considered to be symptoms of COVID lasting for over 12 weeks, or a minimum of 4 weeks. Currently we are not quantifying long COVID in the same way we are the number of deaths, the number of positive tests etc. But we know cognitive symptoms can include poor concentration, memory problems, language problems and “brain fog”. The stress of the pandemic and lockdown have mental health implications for all of us, but for long COVID patients there is also the anxiety of not having their condition and symptoms recognised.
Niall Boyce
What insights can the history of pandemic disease give us into the current situation?
John McConnell
Our world has changed so much. We have learned that pandemics go out with a whimper rather than a bang. The flu pandemic in 2009 and Ebola in West Africa are 2 examples which taught us how to do research. Clinical trials in 2009 were very slow to get off the ground, and the only randomised trial in West Africa which produced a result was the vaccine trial. This taught us a lot about having template research protocols ready for use. And these have been applied remarkably quickly this time.
Niall Boyce
What research needs to be done to determine the precise mechanisms and impacts of the virus in the acute and longer term?
Ed Bullmore
There is more work to be done experimentally with animal models. Such as with the concept of neurotropism [to affect, attack or be attracted to nervous tissue], that the virus can invade the nervous system and reach back to the brain, which is something we can see in animals, and could be linked to the effects on taste and smell. The focus of the research should now be on the clinical side. But we have to move fast, and this is one of the key issues in the research community. There is already post hospitalisation monitoring of about 40 to 50 patients here, and it’s exciting to see how quickly we have got this going. We also need to look at treatments and interventions, and understand the mental health and neurological aspects of COVID. We also need to think about prevention of these mental health and neurological consequences - the vaccines are fantastic, but we need to understand their implications for mental health and the neurological impacts of the disease. Even if the effects of the virus are biological rather than psychological, there can be room for non-biological interventions, e.g. digital.
Niall Boyce
How might the social situation and media discourse be affecting people’s response to contracting the illness?
Maxime Taquet
There might be a biological explanation and a psychological explanation for mental health implications. And a large part of the psychological explanation is the anxiety experienced by those who contract the virus. It would be interesting to see how this has changed with the developing and changing of public messaging around the disease.
Niall Boyce
What can the mental health sciences add to the public health response to this and future pandemics?
Nisreen Alwan
The mental health burden is huge. It is estimated that 10% of all infections will still be unwell 3 months on from the infection. The indirect effects are also important. One big feature, for both direct and indirect impact of the disease, is the huge inequality which can determine access to care, likelihood of contracting the illness etc.
Niall Boyce
How can mental health be successfully integrated into the research and clinical response to the current pandemic?
John McConnell
As discussed, clinical trials have come off the ground quickly, partly due to the templates set up as a result of previous lessons learned. But mental health was not necessarily included in many of these protocols. One clear lesson from this year is that next time we must be ready to ask those questions that characterise the mental health effects of the pandemic from day one, and not leave it as an afterthought.
Niall Boyce
How are practitioners globally and locally coping with the changes in service provision? Digital mental health provision has really taken off and been put into action in the last 6 months, significantly more so than in the last decade. How can this counter the neurological impact of the virus?
Ed Bullmore
Digital is going to be crucial. Also for dealing with the post-COVID environment more generally. In Cambridge we noticed a marked drop off in the number of people seeking mental health support in the immediate aftermath of the first wave. Certainly in the last 6-9 months though there has been a dramatic ramp up of the use of digital in the diagnosis and support for mental health. This can never replace face to face support, but the pandemic has boosted the use of digital and enforced enduring change that would not have otherwise been brought about.
Nisreen Alwan
There are certainly many advantages to all this. But some groups that lack digital literacy etc. will face additional barriers. And these are the groups that we always struggle to gather evidence on - representation is always a challenge. The term “hard to reach” is often used, although the impetus should be on us as researchers to make sure that the findings are applicable to those groups too.
Niall Boyce
Do we see specific effects in the age group of young adolescents?
Maxime Taquet
We’ve not specifically looked at that in terms of the biological impact. But we know that schools closing is happening at an important time in young people’s development and is impactful in the social and psychological sphere.
John McConnell
We know that young people are remarkably free from serious disease and death from this virus in terms of the virological side of the pandemic. But in terms of mental health, we must be very careful to monitor the health of our children who have gone through restriction in their social interaction and schooling that we have never gone through before.
Nisreen Alwan
The mental strain and how young people react to it depends on the individual. Responses vary hugely. We say that children are not affected biologically, but they do not live in a separate bubble and are experiencing second hand impacts from those they are living with etc.
Niall Boyce
Will genome sequencing help us better understand how the virus impacts mental health?
Ed Bullmore
This has already helped us to understand the virus itself. The impact of the new variant on neurotropism, for example, is something that we do not yet know. Genetic variation is definitely something to watch out for in the future in relation to this.
John McConnell
This has always been an additional aspect, but now feels even more important.
Niall Boyce
As a final, short question, what is the number one research priority right now in terms of mental health impacts of the pandemic?
Ed Bullmore
Priorities are: for mental health to not get forgotten, to not get split off and stuck in a silo, and to be in it for the long game.
Maxime Taquet
Therapeutics is very important. We need to know how to treat the mental health consequences of COVID, whether or not this is the same as non-COVID treatment.
Nisreen Alwan
Physical and mental health research should not be separated. The pandemic has had devastating impacts, and we must not forget disadvantaged groups in research and end up widening inequalities.
John McConnell
Chronic fatigue syndrome, which has a neurological and mental health component, is something that is debilitating and not well understood. I wonder if it’s possible that the intense research into the biology of long COVID brings some insights into this.
