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UCL Mental Health Research at the time of COVID

iomh12 May 2021

researcher testing with pipette

This blog was written by Ana Antunes-Martins, Research Coordinator for UCL Institute of Mental Health.

The COVID-19 pandemic has had multiple effects on mental health, some of which are likely to be long-lasting. UCL mental health researchers have been busy investigating how the infection affects the nervous system, how we adapted to life in lockdown, and how we have been coping with the hardships brought by the pandemic. This blog post is a broad overview of UCL’s contributions to the fight against the ‘mental health pandemic’ over the last year. For more in-depth discussions of specific mental health topics and COVID, read our series of blog posts published on the IoMH website over the last year.

Learning from previous coronavirus outbreaks and early COVID-19 data, in July 2020, Jonathan Rogers and Tony David suggested that lasting mental disorders may follow severe COVID-19 infection in some patients (1). They also found that, while thoughts of suicide and self-harm have shown increases in some groups around the world (e.g., the young and those suffering from the viral infection), suicide has not generally increased (2). Perhaps increased social cohesion – the feeling that we are stronger together – has been a protective factor.

But we cannot necessarily rely on this. A group of clinical academics led by Michael Bloomfield banded together to form the COVID Trauma Response Group. The group recommends that COVID survivors should be monitored to address risks of PTSD, anxiety, and depression. Long-COVID sufferers also describe mental health symptoms (fatigue and so-called ‘brain fog’). Two NIHR/UKRI-funded studies will follow Long-COVID patients to understand how the disease progresses, whether it can be treated, and who is most vulnerable. One of these studies, led by the MRC Unit for Lifelong Health and Ageing at UCL, will focus on adults, while the other, led by Great Ormond Street Institute of Child Health, will focus on those who contracted the virus as adolescents.

Beyond the direct effects of the virus, the pandemic caused sudden changes to our lives and livelihoods and put massive strains on society. To understand how these challenges impacted our mental health and wellbeing, UCL researchers conducted interviews and surveys with large numbers of people. Some of these studies were added to ongoing research, while others were set up from scratch. For example, studies at the UCL Centre for Longitudinal Studies are taking advantage of birth cohorts (samples of the population followed regularly since birth) to investigate how mental health and behaviours compare to pre-pandemic levels and change as the pandemic progresses. Another large study is the COVID-19 Social Study, led by Daisy Fancourt, which was set up in March 2020 to keep track of the feelings and habits of 70,000 adults in the UK every week.

These types of studies provided snapshots of our lives during the pandemic: how depressed, worried, lonely, and anxious we felt and how much we slept, exercised, and drank alcohol, and whether we ate our 5-a-day (3,4). Most importantly, because the studies followed such a large slice of the population, researchers could pinpoint which groups struggled the most. Amongst adults: women, younger adults, and those facing financial hardship, those with mental illnesses before the pandemic, and those who were lonely fared poorly in several mental health and wellbeing measures.

UCL researchers homed in on these groups. In many cases, people in these groups already suffered from poor mental health before the pandemic, and the pandemic just made it worse: women’s psychological distress was worsened by increased childcare responsibilities (5), young people were more affected by job uncertainties and worried about the future and consequently more depressed, anxious, and lonely (6), those with precarious working conditions had worse physical and mental health outlooks, and even increased mortality during the first year of the pandemic (7).

The sudden changes brought by the pandemic were particularly challenging to those who already had mental health disorders and saw their support networks and access to healthcare compromised. The Mental Health Policy Research Unit (MHPRU), led by Sonia Johnson, is researching ‘what works’ in mental health services. For example, a literature review of mental health services worldwide, identified the evidence needed to inform policy and best practice (8). Central to this research is the voices of those with lived experience. In this spirit, the MHPRU and the Loneliness and Social Isolation Network work with ‘experts by experience’ to co-develop surveys and interviews to understand the specific challenges faced by the patients and how they can be supported, especially in navigating remote health care (9).

Loneliness is a big player in poor mental health. The good news is that maintaining remote contact with friends and family (10) and engaging in arts (11) may be helpful tools to combat loneliness and improve mental health. The ‘Community COVID’ study led by Prof Helen Chatterjee will address how well ‘creative resources’ work to improve mental health and how we can make the most of them.

Children and adolescents had their routines and social lives completely changed by school closures. Researchers at the UCL Institute of Education and the Anna Freud Centre are devoting significant efforts to understanding pupils’ experiences from different ages and socio-economic backgrounds (12,13). They ask who coped better and worse (and why), what pupils found most upsetting, what they did to improve their moods, how families managed, and whether school staff could cater to children’s wellbeing remotely. But research is only worthwhile if it can help people, and these researchers are doing precisely that, by producing up-to-date homeschooling resources and lay summaries to help families support their children’s wellbeing.

So, what next? Fourteen months since the beginning of the pandemic, the UCL mental health research community has generated invaluable data and resources to help society and individuals cope better and hopefully, to some extent, reduce the long-term repercussions of the pandemic. Lessons learned to date have informed clinical mental health practice, education, social and community support strategies, and will have impacts well-beyond the pandemic. Of course, there are many unanswered questions, and studies that are just starting, and we look forward to hearing what this new research holds.

 

References

  1. Rogers, J. P. et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 7, 611-627, doi:10.1016/S2215-0366(20)30203-0 (2020).
  2. Rogers, J. P. et al. Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis. Epidemiol Psychiatr Sci 30, e32, doi:10.1017/S2045796021000214 (2021).
  3. Villadsen, A. et al. Mental health in relation to changes in sleep, exercise, alcohol and diet during the COVID-19 pandemic: examination of four UK cohort studies. medRxiv 03.26.21254424; doi:https://doi.org/10.1101/2021.03.26.21254424
  4. Saunders, R., Buckman, J. E. J., Fonagy, P. & Fancourt, D. Understanding different trajectories of mental health across the general population during the COVID-19 pandemic. Psychological Medicine, 1-9, doi:10.1017/s0033291721000957.
  5. Xue, B. & McMunn, A. Gender differences in unpaid care work and psychological distress in the UK Covid-19 lockdown. PLoS One 16, e0247959, doi:10.1371/journal.pone.0247959 (2021).
  6. https://www.ucl.ac.uk/ioe/news/2021/apr/more-half-16-25-year-olds-fear-their-futures-and-job-prospects
  7. https://www.ifow.org/resources/the-good-work-monitor
  8. Sheridan Rains, L. et al. Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses. Social Psychiatry and Psychiatric Epidemiology, 1-12, doi:10.1007/s00127-020-01924-7.
  9. Gillard, S. et al. Experiences of living with mental health problems during the COVID-19 pandemic in the UK: a coproduced, participatory qualitative interview study. Soc Psychiatry Psychiatr Epidemiol, doi:10.1007/s00127-021-02051-7 (2021).
  10. Sommerlad, A. et al. Social relationships and depression during the COVID-19 lockdown: longitudinal analysis of the COVID-19 Social Study. Psychol Med, 1-10, doi:10.1017/S0033291721000039 (2021).
  11. Mak, H.W. et al. Predictors and Impact of Arts Engagement During the COVID-19 Pandemic: Analyses of Data From 19,384 Adults in the COVID-19 Social Study. Front Psychol, doi: 3389/fpsyg.2021.626263 (2021)
  12. https://www.ucl.ac.uk/ioe/research/covid-19-research-ucl-institute-education/research-related-covid-19
  13. https://www.annafreud.org/coronavirus-support/our-research/

Architecture and Mental Health – How built environment and healthcare professionals can work together to improve psychiatric environments

iomh11 May 2021

patient room

This blog was written by Dr Evangelia Chrysikou, Lecturer at The Bartlett School of Sustainable Construction, Program Director of the MSc Healthcare Facilities at UCL and medical architect.

Foucault’s History of Madness (1964) was the book that triggered my interest on spaces for psychiatric patients. Even though the spaces of confinement where not the purpose in the book, being an architect with skills on visualising spaces, those asylum buildings provided an incredibly dystopian scenery for the actual context. It was clear to me that those spaces, even if that were not necessarily the intention, were facilitating the alienation of mentally ill people at multiple levels, from social to personal. Looking at the plans and the narratives one could understand that deprivation and inequality were principles embedded in their architecture. So, what was the situation now, what was the physical context of mental illness? Did the movements of anti-psychiatry or the efforts for psychiatric rehabilitation have a tangible effect in stopping this coercive paradigm of neglect and at the same time help facilitate the change that was happening at that time in the care for psychiatric patients? This was in the mid-nineties, at a period where in several parts of Europe the old asylums would be gradually replaced by smaller psychiatric facilities, mostly but not necessarily in the community, in an uneven journey of trial and error. I started working with the teams that moved the patients from the notorious Leros asylum back to the community. I soon realised that the available literature was mainly from health services research rather than architecture. The new paradigm advocated for small (but then how small?), domestic (but what does this actually mean?) structures of various types and purposes, preferably in the centre of their catchment area with welcoming accents of tablecloths and cutlery. Those descriptions reflected how a healthcare professional would describe spaces but would leave a lot unanswered in terms of an architectural inquiry. Taking people from Leros asylum to their original places in mainland Greece was a task for the psychiatrists. How they would bring people back from a courtyard where the single tree was always leafy –a eucalyptus tree– so patients did not know what the word “autumn” meant and they had forgotten the seasons. How would they explain inner city traffic jams and crossings to somebody who left their rural village in the thirties, or modern flats and electrical appliances? How would these people be transferred into the modern era and in a busy urban context that they had never met? What sort of buildings should facilitate this transition?

This is where my research started. I had to look at the available provision first in Greece and then to Belgium, the UK and France. I could see a variety of structures, urban or rural, embedded in the community or isolated, small or multi-storey and complex, with different levels of security, interaction and stimuli. There was no unified model of care and that was apparent if one looked at the building stock. My research initially looked at these various options and then I concentrated on understanding the therapeutic spaces available for the acute spectrum of mental illness. I involved patients and staff and sought to understand their perspectives on how such spaces should be shaped. It was the first time that a researcher asked psychiatric spaces to give feedback about the place and space of the wards. At the same time I evaluated the architecture of spaces using theories of space and place making. My research generated various tools: a very useful one and very simple to use was a checklist that classified the psychiatric buildings in terms of domesticity vs institutionalization and the SCP model for the planning and evaluation of psychiatric spaces (Chrysikou, 2014). For the benefit of PhD researchers, you might be interested to know that the model was developed from my PhD and has shaped much of my research since as well as providing a useful tool for other research projects I have been involved over the years, including my Marie Curie Individual Fellowship project (Chrysikou, 2019). This model offers a three dimensional perspective of analysing psychiatric buildings in relation to their therapeutic purpose. Each axis refers to a different priority –safety and security, competence and personalisation and choice—and at the same time refers to a different era in the design for mental health –the coercive, the medical and the psychosocial (Figure 1). That way, professionals and stakeholders involved in the planning, the design and the evaluation of such premises can have context and references, even for simple decision-making. For example, in the case of a forensic facility we need to focus more on safety and security as dangerousness might have a significant impact, but at the same time we have to think and acknowledge clinical needs and the ultimate aim of psychosocial rehabilitation and the principles of valorisation that could still be suitable for forensic accommodation. So, we would have secure windows but at the same time we could prioritise views to green and blue. The tools developed would help evaluate the environment of the wards in relation to their surroundings, the closed space within the ward and even details.

When I first conducted research in the UK in the late nineties, I could detect remnants of the previous mental health care model, the medical model, in the architecture of the wards. The older wards might be situated in hospital premises and even if they had evolved they still retain general ward typologies. Those co-existed with some new typologies, experimenting on what a psychiatric ward should be. Those would demonstrate investment in design and innovation. This period of experimentation has been replaced by a more uniform reality supporting single ensuite rooms, light spaces and the introduction of visual art. Yet, at the same time we could detect some institutional re-introductions in the name of anti-ligature: bathroom fixtures and fittings that cannot cause harm but are quite uncomfortable to use, heavy, immobile furniture very similar to what the old asylums would have, absence of door panels or drawers in storage units, making clutter more visible. To a system that is understaffed such practices prove a viable solution yet at the same time convey the message that patients are not to be trusted. They are also present in North American psychiatric hospitals but we do not see them in the European equivalents, making the comparison inevitable. More cross-country comparisons would be important to help us learn from those differences. Transdisciplinarity would be another critical element for future research. As psychiatric environments have to support a variety of functions and purposes, they present challenges that other types of healthcare environments do not necessarily have. Transdisciplinary and user-inclusive research would be our best chance to capture that complexity. Researchers from health disciplines have to collaborate with researchers who are familiar with built environment perspectives and grow the area in between.

References

Fouqault, M. (1964). Histoire de la Folie, a l’ age classique. Paris: Plon

Chrysikou, Ε. (2014). Architecture for psychiatric environments and therapeutic spaces. Amsterdam: IOS Press. ISBN 978-1-61499-459-6

Chrysikou, E. (2019). Psychiatric institutions and the physical environment: combining medical architecture methodologies and architectural morphology to increase our understanding. Journal of Healthcare Engineering, vol. 2019, Article ID 4076259, 16 pages, https://doi.org/10.1155/2019/4076259

Figure 1: The SCP model

Biography

Dr Evangelia Chrysikou is Lecturer at The Bartlett School of Sustainable Construction, Program Director of the MSc Healthcare Facilities and medical architect. She is Vice-President of the Urban Health Section (EUPHA) and RIBA Chartered Member. She specialises in healthcare facilities, holding a rare PhD on mental health facilities from UCL and a very prestigious Marie Curie H2020 Individual Fellowship. She has been actively involved in policy, being Coordinator on D4 Action Group of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) of the European Commission (EC). Evangelia has received several international awards for her healthcare architectural projects and her research. She authored the national guidelines for mental health facilities in the community for Greece on behalf of the European Union. Additionally, she authored the books ‘Architecture for psychiatric environments and therapeutic spaces’ and ‘The social invisibility of mental health facilities’, is a healthcare architecture editor, reviewer, active member of several professional and scientific associations and TED-MED speaker.

Interview for the UCL-Wellcome 4-year PhD Programme in Mental Health Science by Humma Andleeb

iomh2 March 2021

profile photo of phd student humma andleeb

This is a series of blogs about my experience of the UCL-Wellcome Mental Health Science PhD programme.  It will cover applying for the programme, the interview and lead up to enrolment stage of the programme as well as my experience of the programme and my PhD. I am publishing these blogs for prospective students in response to the queries I have received about the programme in response to my Twitter thread  on successfully securing a place on the programme.

Having applied to the UCL-Wellcome Mental Health PhD programme at the end of January 2020 (read my blog post on applying here), I was shortlisted for an interview, much to my surprise. We were told that we would be presented with a 30-minute task that would consist of a series of abstracts and the interviewee would be asked to summarise the abstract in lay language for the general public. Following the task, a 30-minute interview would take place with a panel consisting of members of the committee.

At the time, COVID-19 was beginning to spread rapidly especially in London and we were given the opportunity to have a virtual interview or have a socially-distanced in-person interview. I opted for an in-person interview, due to personal preference, but as things escalated the weekend before the interviews were due to take place, we were all given the opportunity to have a virtual interview and reassured that there would be no impact on our outcomes if we did opt for a virtual interview. I decided to go ahead with the original plans and have an in-person interview.

Preparing for the interview

In preparation for my interview, I revisited my application form and looked up some online resources on how to prepare for a PhD interview. Looking back at my application, I focussed on areas that might interest the panel and areas that I could potentially expand on at interview. Using online resources that provided guidance and feedback from interview experiences helped to guide me in preparing for questions that I may be asked relating to the programme and my application as well as think about questions that I had about the programme and the university. However, I noticed that resources online tend to focus on specific PhDs with a specific supervisor and assume that you already have a thesis title; therefore, it’s important to note that this programme is different, in that it is a 1+3 programme and is for a generic Mental Health Science PhD, so there is less need to focus on specific background research in one area. The focus of the programme being interdisciplinary also comes into this, as collaboration across the three main themes (Mechanism, Population and Intervention) is heavily encouraged and forms the basis for the programme.

The interview

On the day of the interview, I got the bus from my South London home to Bloomsbury and walked to the Institute of Cognitive Neuroscience where the interview was due to take place. As someone who is either very late or very early, I decided to make a conscious effort to be VERY early, so I arrived before the building had even opened! Thankfully, I didn’t have to stand outside for very long before the receptionist arrived, and I had plenty of time to look through the notes I had made in the foyer area (after sanitizing my hands of course!). The panel members began arriving and there was an interview scheduled before mine, but time went really quickly as I skimmed through my preparation notes and before I knew it, it was time to start the task. Whilst working on the task, I was anxious that I’d forget all my preparation for the main interview so it was a plus that all that was required of me was to summarise the abstract (I’m not sure I could have done anything more complex than that!).

Due to the nature of the unfolding pandemic, some of the panellists joined the interview via Zoom and others were there in person, but the room was set up to ensure that we could all communicate and see each other. Another thing that immediately stood out to me was that there was no daunting row of mean-looking panellists sitting across from the interviewee, ready to pounce on you. Instead, they all introduced themselves and gave some insight into their role on the programme and their job before outlining how the interview would go.

The interview itself felt like a conversation and all of my worries disappeared once I settled into the atmosphere and noticed the welcoming nature of the panel. Usually, I’d want the interview to end as soon as possible, but in this interview, I could have carried on talking about how great the programme was and its potential in encouraging collaborative research in mental health science. I was able to express my passion for interdisciplinary research, my previous research experience and my wider interests and hobbies. It was evident from the discussions that this programme is not just about academic achievement but also about ensuring students are well supported and trained in areas that will help shape our futures as mental health researchers and people.

I went in thinking of the panel as my colleagues and I felt like that was reciprocated by the panel. I left the interview on a bit of a (natural) high but, after a while, started kicking myself for some of the responses I gave – and things I had prepared that I did not have time to mention. But this is completely normal and there’s never enough time to share everything, so I was sure I did the best I could possibly have done and about an hour later, I forgot what had even been discussed! I had emphasised all I could to highlight why I felt I was an ideal student for this programme, now the decision was in the hands of the committee… all I could do at that point was to wait and hope.

As I share my personal experience, I’m aware that one person’s experience may differ greatly from the next, and other students in the cohort had virtual interviews, so they have kindly offered their reflections and experiences below:

Rosalind McAlpine: “I found the interview (surprisingly) enjoyable! I was slightly nervous about the pre-interview task, but the interview panel created an inviting and supportive atmosphere and my anxieties were immediately dissolved. As I was studying in America at the time, I completed my interview online and – prior to it starting – I was slightly apprehensive that things would be awkward due to the digital nature of the interview. However, the panel were clearly very experienced in conducting these sorts of interviews because I never felt as though I was being spoken over or speaking over someone, and the interview had a pleasant, reciprocal dynamic to it. I felt the questions they asked me were completely appropriate and allowed me to demonstrate why I wanted to join the programme and what I hoped to gain from it. Similarly, I felt comfortable in asking any questions that popped up and felt I was heard throughout.”

Thomas Steare: “Interviewing for a Wellcome-funded PhD at University College London is quite a big deal. Naturally I was nervous despite the numerous practice interviews I had done the week before. A great thing about the programme is its emphasis on supporting students and their well-being. This was evident throughout the interview as the panel made a big effort to be supportive and engaging. My anxieties quickly subsided when the interview commenced, and I soon enjoyed answering the interviewers’ questions and explaining why I was so interested in studying a PhD with a focus on interdisciplinary research methods.”

Giulia Piazza: “March 2020 was a strange month for many reasons. I was very surprised to be invited to an interview for the UCL-Wellcome 4-year PhD in Mental Health Science. I remember being incredibly nervous –  I practiced a lot, and thankfully the panel was extremely welcoming and reassuring. I thought all questions were fair and relevant, and tried my best to explain why I so badly wanted to join the programme. If you have been shortlisted for an interview, here is my advice. Keep going despite technical mishaps. You might feel like you haven’t answered a question as best as you could have, but don’t lose hope throughout the interview. No one will be trying to trick you or get you to make a mistake: your interviewers really want every candidate to perform at their best, and they understand people will naturally be anxious on the day. Genuinely answer with your opinions, rather than thinking about what you believe the committee wants to hear. And lastly (and this is the hardest part), try not to be too hard on yourself!”

If you have been shortlisted and are currently preparing for your interview, my main tips would be:

  • Use your application to guide your preparation. You have been shortlisted based on your application so use this to your advantage, and think of the interview as an opportunity to expand and reinforce what is included in your application
  • Spend some time thinking about and preparing what you want to prioritise sharing in the interview
  • Think about what the panel will want to know about you in order to gauge whether this programme is the right fit for your experience and passion for research and consider what they are looking for in a candidate
  • Interviews don’t have to be daunting – framing them as a conversation with a new colleague about your previous experience and your aspirations, as opposed to giving answers to difficult questions from scary academics, might make it easier to prepare.
  • Remember that there is more to you than just your academic achievements, and being a good candidate is about more than just having a longlist of experience and accolades
  • Think about any questions you may have about the programme and use the interview opportunity to ask the committee members

Humma Andleeb is on the 4-year PhD programme in Mental Health Science at UCL. She has an academic background in biochemistry and neuroscience and previously worked at The McPin Foundation, using her lived experience of mental health difficulties to inform mental health research. She is passionate about patient and public involvement, specifically involving minoritised communities furthest away from the research field. She is a regular book reader, sourdough baker and lifestyle podcast listener. You can find her on Twitter: @HummaAndleeb

Suicide and COVID-19: ‘Careless Talk Costs Lives’

tonydavid8 February 2021

Suicidologists, not famed for their optimism, are bracing themselves for an increase in suicide rates following the pandemic. Some have called it a perfect storm (1). It is not an easy subject to discuss for two main reasons. A person bereaved by suicide described it to me as like having a hand grenade explode in your living room. But precisely because suicide is such a singular event, it can only really be studied – in a way that useful lessons can be learned – from a distance, looking at large numbers and trends over time, by taking a kind of aerial view. The other reason is contagion. That’s why there are strict guidelines from the ‘Samaritans’ and others, on the way suicide is reported in the media (2) – which include avoidance of sensationalism, of the idea that the act is heroic, dwelling on methods, and that suicide was inevitable – for fear of copycats. Indeed the worst kind of newspaper reports did emerge early in the pandemic from India of people unexpectedly and violently taking their own lives after being told they had the virus but this did not continue and mercifully did not foretell of any similar trends. And I am conscious of even now having to be careful about my use of language even in the context of an article intended for a largely academic and educated audience (3,4).

Even asking about suicidal thoughts in a clinical context has made people anxious that it ‘puts thought into people’s heads’. Reassuringly, summarising several studies on this question, authors of a systematic review conclude that it is safe and can, as would be hoped, relieve distress (5). Our instincts and those motivating the bulk of mental health awareness campaigns tell us that it is good to talk. I should add that listening to someone who looks you in the eye and tells you of their intention to kill themselves feels like that grenade has just landed in your lap. It’s not an easy subject to talk or hear about.

Knowing of the possibility of suicide is arguably the uniquely human existential curse, as elaborated by 20th Century philosophers like Heidegger. But does being reminded of it really make a difference? Goethe’s hapless hero Werther takes his own life due to unrequited love. This sparked a minor craze in the mid 1770s of imitations by romantic young men donning the same blue coat and yellow waistcoat, and leaving the tell-tale eponymous novel by their sides. The moral panic that ensued has repeated itself many times with ‘13 Reason’s Why’ being a notable recent example (6).

Such outbreaks, spatial-temporal clustering to use the technical term, are fiendishly hard to prove statistically (7). In the age of social media and the internet the ‘where’ of a suicide hardly matters – unless within an institution like a prison or a psychiatric hospital – and the timing of a cluster is not obvious either; the next day, week, month? Indeed if there is to be an increase in suicides in the wake of this pandemic when should we expect it? Suicide statistics accumulate slowly and in the UK may wait months for a coroner’s verdict. Suicide is, thankfully, rare enough that it takes a while to see enough instances to say whether rates have increased even nationally, in comparison to, for example, the same time last year, even using provisional statistics.

Efforts have been accelerated around the world by the pandemic to provide real-time surveillance information so that rates can be tracked and if rising, perhaps mitigated (8). Early reports from Queensland Australia (pop approx. 5m) have made use of police reports to the coroner. There were tragically 434 suicides from February through August 2020, a rate which did not differ compared to the preceding 5 years (9). The social context of the suicides did not show any particular emphasis on say unemployment or domestic violence and just 36 were judged initially at least as being related to Covid-19 – in what way, was not made explicit. A study from Japan (10), which has suffered less than the most European countries from the pandemic, normally has an average of 1596 suicides per month but this dropped by 14% between February and June last year but then increased by 16% in July to October. Interpreting such fluctuation is tricky. Could it be that suicide was delayed during the first wave only to rebound or are we seeing a cumulative effect? The study authors wonder whether it has to do with the prospect of withdrawal of government financial support packages. Work in progress reported by the UK’s National Confidential Enquiry into Suicide and Safety in Mental Health shows no increase in the monthly average from April-August 2020 compared with Jan-March (11). A similar picture of no increases is emerging from Norway (12) and preliminary data from the US (8).

The nearest we have in the UK to official rolling figures are monthly statistics on mortality in people under 18 (13). In the 82 days before the first lockdown in March 2020 there were a heart-rending 26 deaths by suicide compared with 25 in the first 56 days after, an post-lockdown increase in rate by about 40% but with a very wide margin of error such that the difference fails to meet conventional levels of statistical significance. A third of the young people were known to services.

Experience from the Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong in the spring of 2003 – also caused by a coronavirus (14) showed an uptick of about 30% in deaths by suicide paralleling SARS mortality – over its 4 month course (15). This affected older women particularly, a group more prone to suicide in China for some reason unlike the general rule around the world that older men have the highest rates. However the summer peak did not occur leading the authors to wonder if suicide had simply been brought forward by the epidemic (16).

What of the Spanish flu pandemic of 1918-19? Very little data on suicide are available but one US (17) and one Swedish study (18) using fairly reliable contemporaneous figures found no increase. It’s true, that there was a lot going on then! The Great War (like all wars) showed the expected drop in suicide, perhaps due to an increase in social cohesion, followed by an increase which coincided with Spanish flu, so teasing out the effects of each is impossible. As an aside, rates following the two world wars did rise again but not quite to pre-war levels and then peaked around the great depression. Rates in Europe and the UK have been gradually falling ever since. Indeed if there is a predictable harbinger of increased suicide on the large demographic scale it is economic hardship. It is therefore suicide rates over the next few years that will be most scrutinised.

There is no vaccine for suicide but there are some ways to increase immunity. Social proximity, economic support for those in poverty, agile and responsive mental health services, control of alcohol consumption being the most obvious.

One of my patients etched on my memory suffered depression severe enough to require in-patient care. He was driven to despair by religious guilt over a seemingly minor misdemeanour. As his mood improved with antidepressants and psychological support there seemed to be a glimmer of light, and he’d had enough of all that ‘religious nonsense’. I was reassured only for him to take his own life dramatically during a period of home leave a few weeks later (see 19). My lesson: whatever binds people together in society – shared values, beliefs, rituals – keeps us alive, regardless of their rationality.

In sum, when it comes to suicide, especially in the midst of a pandemic, it may be good to talk but it depends what you say. We might remember the WW2 safety slogan – “careless talk costs lives”. Perhaps the next mental health awareness campaign should be promoting the benefits of listening. Listening to what people are saying as well as what evidence and data are showing; we all need to try and learn from that.

And for every Werther there is a Papageno from the Magic Flute or George Bailey in ‘It’s a Wonderful Life’ – numinous tales of people turning away from suicide thanks to others sharing ways to value continued living – despite moments of desperation. Don’t ever say it’s inevitable.

Professor Anthony David

Director, UCL Institute of Mental Health

 

References:

  1. Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019—a perfect storm? JAMA Psychiatry. 2020. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2764584
  2. World Health Organization. Preventing suicide: A resource for media professionals. 2017 https://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/.
  3. Gunnell D, Appleby L, Arensman E et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020. 7: 468–71. http://www.ncbi.nlm.nih.gov/pubmed/32330430
  4. Hawton K, Marzano L, Fraser L, Hawley M, Harris E, Lainez Y. Reporting on suicidal behaviour and covid-19—need for caution. Lancet Psychiatry 2021. 8:15-7. doi: 10.1016/S2215-0366(20)30484-3.
  5. Polihronis C, Cloutier P, Kaur J, Skinner R, Cappelli M. What’s the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal, Archives of Suicide Research, 2020. DOI: 10.1080/13811118.2020.1793857
  6. Ortiz P, Khin E. Traditional and new media’s influence on suicidal behavior and contagion. Behaviour Science and Law. 2018. 36:245–256.
  7. Niedzwiedz C, Haw C, Hawton K, Platt S. The definition and epidemiology of clusters of suicidal behavior: a systematic review. Suicide Life Threatening Behavior.2014. 44, 569–581.
  8. John A, Pirkis A, Gunnell D, Appleby L, Morrissey J. Trends in suicide during the covid-19 pandemic: Prevention must be prioritised while we wait for a clearer picture. BMJ 2020;371:m4352
  9. Leske S, Kõlves K, Crompton D, Arensman E, Leo DD. Real-time suicide mortality data from police reports in Queensland, Australia, during the COVID-19 pandemic: an interrupted time-series analysis. Lancet Psychiatry 2021; 8: 58–63
  10. Increase in suicide following an initial decline during the COVID-19 pandemic in Japan. Tanaka T, Okamoto S. Nature: Human Behaviour. 2021. doi.org/10.1038/s41562-020-01042-z
  11. National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide in England since the COVID-19 pandemic- early figures from real-time surveillance. 2020. http://documents.manchester.ac.uk/display.aspx?DocID=51861
  12. Qin P, Mehlum L. National observation of death by suicide in the first 3 months under COVID-19 pandemic. Acta Psychiatr Scand 2020.pmid: 33111325
  13. National Child Mortality Database. Child suicide rates during the covid-19 pandemic in England: real-time surveillance. 2020. https://www.ncmd.info/wp-content/uploads/2020/07/REF253-2020-NCMD-Summary-Report-on-Child-Suicide-July-2020.pdf
  14. Rogers JP et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020. 7: 611–27. http://www.ncbi.nlm.nih.gov/pubmed/32437679
  15. Chan SM et al. 2006. Elderly suicide and the 2003 SARS epidemic in Hong Kong. International Journal of Geriatric Psychiatry 2006. 21: 113–18.
  16. Cheung YT, Chau PH, Yip PSF. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. International Journal of Geriatric Psychiatry 2008. 23: 1231–38
  17. Wasserman IM. The impact of epidemic, war, prohibition and media on suicide: United States, 1910–1920. Suicide and Life‐Threatening Behavior 1992. 22: 240–54.
  18. Rück C, Mataix-Cols D, Malki K, Adler M, Flygare O, Runeson B, Sidorchuk A. Will the COVID-19 pandemic lead to a tsunami of suicides? A Swedish nationwide analysis of historical and 2020 data. medRxiv preprint doi: https://doi.org/10.1101/2020.12.10.20244699
  19. David A. Into the Abyss: a neuropsychiatrist’s notes on troubled lives. Oneworld Publications, 2020, London.

 

Awareness is just the start

tonydavid9 October 2020

World Mental Health Day 2020 poster by Mental Health Foundation

World Mental Health Day 2020 poster by Mental Health Foundation

The 10th October 2020 is World Mental Health Day. This marking of the calendar was launched in 1992 by the World Health Organisation and has become well established. The UK Charity, the Mental Health Foundation proposed a regular awareness week (occurring in May – 18th to 24th this year), back in 2001. Time to Talk day was 6th February 2020, following Blue Monday – 20th January – spuriously claimed to be the most depressing day of the year. In fact, there are mental health days or weeks for fathers, mothers, men and women in general, children (3rd– 9th Feb) and many more – helpfully gathered on the website: therapyforyou.co.uk/post/mental-health-calendar.

It would be easy – and wrong – to be cynical about all this. Wrong because awareness should be the first step towards understanding – for those who are ignorant or unduly frightened by mental illness. Greater awareness in the minds of politicians, philanthropists and scientists should lead to more research and better funding for services. Above all, greater awareness should replace prejudice and stigma with realistic appreciation and empathy. However, as with many anti-stigma initiatives, this can have unintended consequences (watch my talk on this for last year’s World Mental Health Day). In the case of awareness days and weeks – it can lead to complacency and apathy. A better response is to try and propel the agenda forward from awareness to deeper understanding and most important of all, action.

One undeniably positive consequence of greater awareness is the empowerment of people with lived experience of mental health problems to not only tell their stories in their own words but also to become an essential part of “the solution”. I put that in inverted commas to indicate clearly that there is certainly no simple or single solution to mental illness or disorder but that research – from basic science to clinical care to public policy – is the driver towards such an ideal.

The UCL Institute of Mental Health (IoMH) is lucky to have on its advisory board a number of highly qualified and motivated  individuals who are able to use their experience of being patients (let’s not say ‘users’) and carers within the psychiatric care system. Here Jackie Hardy and Jason Grant share some thoughts prompted by World Mental Health day.

Nothing about us, without us

I have welcomed being involved in the IoMH and some mental health research with UCL looking at COVID19 and its impact on people’s mental health during this exceptional period in history. The research really has tried to involve Lived Experience Researchers in all pieces of the work, which I have so welcomed. It will be good when some of the papers around this come out.

Being involved has meant I have felt part of something and can share my lived experience in helping to shape things.

Right now we live in uncertain times and I feel mental health services are due an overhaul and have been for a long time. Despite statutory services asking people with lived experience of mental distress, and carers, their views, the same medical model still seems to exist. I would like to see the social model of disability embraced, along with a model of peer support, designed and delivered by people with lived experience of mental distress. Unless you have been there you really cannot know what it is like. The right model of peer support has the person leading their discovery journey – I prefer this term, as ‘recovery’ is pressure; so many of us discover a lot about ourselves, but may never truly recover, as it can be very up and down, as life has its events.

Mental health services should be holistic, looking at the whole person and their whole life and be ‘person centred’. We are all unique individuals, so please do not try to put a square peg in a round hole. Such support needs to be joined up with health professionals and our support network (if we have one, if not ask peers if they can help link the person in to a support network).

If peer support can be person centred, why cannot statutory services? If you do not know how, then please, please talk to us – “nothing about us, without us”, is a term regularly used.

One place to start is NSUN https://www.nsun.org.uk/ – they are: “a network of people and groups living in England who have and do experience mental distress and want to change things for the better.” They can help with research, decide on what should be researched by reaching out to their network of people. I would like to see more lived experience researchers, along with us receiving funding, leading in research and on papers. We can work and learn together.

Change is long overdue, so this is my personal plea for a change.

Jackie Hardy

From Patient to Peer-Support Worker

In the summer of 2015, I had a psychotic episode whilst travelling in Brazil and ended up walking around for three days without sleeping. As I had no insight at the time, I thought that it was just a bad experience and thought nothing more of it. I even went travelling again in Europe a month later where I experienced another psychotic episode. This time I was taken to a psychiatric hospital in Prague and my family had to come and get me out of the country.

I still wasn’t entirely sure what was happening and resolved to not go travelling again for a while. Unfortunately for me, I had another psychotic episode and ended on a section 136 (brought into hospital as an emergency) in Eastbourne Hospital. After being admitted onto the ward for a couple of days, I was then transferred to Meadowfield in Worthing. At this point, I finally realised that it was my mental health that was causing me all of the problems that I was facing and I was determined to do something about it.

I made sure that my time in hospital was spent doing as many activities as possible, from mindfulness, art classes, playing basketball and badminton, walking around the grounds, and even making paper birds using origami.

I was discharged after 10 days into the care of the Crisis Team who referred me to the Early Intervention Service.

I had support for a couple of months then was transferred to Glasgow services as I decided to go back to university. When I returned to Sussex, my care continued for just over three years. During that time, I was able to receive support from a care co-ordinator, participated in various research studies, attended groups and meetings within the Trust, and managed to gain insight around my signs, symptoms, what to do in a crisis and how to manage my condition.

Just to clarify, psychosis is a condition which affects the mind. It changes the way you think, feel, and behave. Some may lose sense of reality and fall into their imagination. Psychosis can occur when drug misuse is an issue and as a reaction to extreme stress or trauma. Psychosis can happen to anyone and like any other illness, it can be treated.

In March of 2020, I interviewed for the position of peer support worker within the same Early Intervention Service that I went through and was successful in securing the role. It took a little while to finally get into post, due to the pandemic and remote working, but I have been working part time since August.

For those that don’t know, Early Intervention is a community-based service for people aged up to 65 years old who are experiencing their first episode of psychosis. The idea is to help people have a positive first experience of mental health services, to reduce symptoms and support recovery, to support the family/carers and involve them as much as possible, and to use evidence-based treatments for psychosis.

The team consists of doctors, nurses, social workers, occupational therapists, psychologists, pharmacists, and peer support workers (of which I am the first in the team). My role is to provide an element of hope based on my recovery, resilience, and self-determination. I will also be able to help others navigate the service and signpost people to other peer activities within the Trust like working-together groups, recovery college, and people participation.

Jason Grant

The academic conference: a Total Perspective Vortex with cappuccinos

tonydavid1 September 2020

In anticipation of the UCL Institute of Mental Health’s first international Conference on 9th September, I posed a few questions to our speakers about their attitudes and experiences of scientific conferences. In this Covid-19 world we are having to rethink many aspects of life we previously took for granted – from the most profound to the trivial (I am not sure where conferences sit on this dimension).

The first question was:  What do you most miss/not miss about ‘conventional’ (pre-Covid) scientific conferences?

For Argyris Stringaris it is the sheer randomness of the encounters that academic conferences engender. For Emily Holmes it’s about sharing cups of coffee and informal chats around the symposia. “Getting to know the people behind the research” as much as hearing about the research alone is the key. Meeting people behind the scientific papers that you have read is a truly eye-opening experience, but not always positive. Some say you should never meet your heroes. I find that I am increasing left feeling that the person whose work I have admired invariably turns out to be much younger than I had imagined. Perhaps this is evidence of a bias to equate longevity with wisdom – a self-serving bias of course. Tamsin Ford agrees – except it’s “a good-sized mug of tea” that she yearns for rather than coffee, but certainly not the jet lag, the delays in immigration and the inevitable traveller’s fatigue.

This is particularly salient for Ethel Mpungu who is based in Uganda. “At the moment, I do not miss ‘conventional’ (pre-COVID) scientific conferences outside my country” she says. “The fatigue from the long distance travel was just about to kill me!… For now I will enjoy the international conferences in the comfort of my office. Before Covid, in-country conferences were attended by very few individuals but with virtual conferences up to 300-500 may attend which I find absolutely amazing. I know that my work has reached so many more people in my country during the Covid pandemic than before.” And we anticipate reaching over 500 this time round.

But what of the actual ‘work’ of the conference format. Pasco Fearon laments the absence of live question and answer sessions from the floor. “I do rather miss formulating a polite answer to the inevitable left-field, really long and rambling question – posting questions online and having the chair choose them has killed that sport.” (We will try and keep this sport alive on September 9th). But who misses those other staples: “This isn’t so much a question as a comment…” and the embittered, entitled question that barely conceals the admonishment: why didn’t you cite my work?

Finally there is the longing for international travel and cultural exchange. For Rick Adams it’s the glorious Italian food at the Schizophrenia International Research Society in Florence every other spring, and American music at Society of Biological Psychiatry.

The second question put to our guests was:  What scientific conferences do you most enjoy?  eg., small focussed symposia? Large scale extravaganzas?

Here I can report that the data were fairly consistent and convincing. The small symposia were considerably more appreciated – “small all the way” according to Rick Adams – but even here it is hard to separate the academic aspects from those more social. Pasco Fearon again: “I much prefer the smaller conferences where there’s a tighter focus on an area of interest; old friends and new stars get to meet, talk in-depth and socialise. I find the big conferences a bit like the Total Perspective Vortex in the Hitchhiker’s Guide to the Galaxy!”

Some like to have their cake and eat it. “I love small focussed symposia (which allow discussion and debate)”, says Emily Holmes, “…but within Large scale extravaganzas to catch up on the big picture.” The same story comes from Tamsin Ford, for whom it’s the American Academy of Child and Adolescent Psychiatry’s ‘research institutes’, “… where a whole day is devoted to a project – some of these have been excellent” – a kind of small-within-large format.

Clearly if it’s about getting your message out to the largest number of people, the large-scale events deliver on their promise and that is what swings it for Ethel Mpungu.  For Jim Gold it’s all about catching up with old friends – more likely in the big international events – although for him the real purpose seems to be seeing who has or has not aged well. It reminds me of a class reunion I went to – often the scene of repressed competitiveness – where the most coveted prize was, not for the most successful or wealthy but for the person who looked most “well preserved”.

The final question was as follows:  What is the single most important scientific/clinical question in our field right now?

Perhaps surprisingly given the scope of the question, there was something approaching a consensus. For Jim Gold and Ethel Mpungu – it’s simple. “When will clinical neuroscience actually impact clinical care at a large scale?” says Jim, while Ethel wants to know, “How interventions work and for whom”.  Argyris Stringaris is equally succinct: “What is mood and how to influence it?”

Pasco Fearon circles the question before homing in: “How can we make programmatic mental health prevention really work? It’s one of the holy grails of the field, but it’s fraught with difficulties.” But like all good research, attempting to answer one question always leads to many more: “How do we sustain intervention effects over long periods of time? In child psychology and psychiatry there are a good number of prevention and intervention strategies that seem to be helpful in the short-term, but their benefits often fade over time. Good strategies for maintaining treatment gains might sometimes be quite different to the strategies that affected change in the first place, but we rarely think about this thoroughly or study it.”

Emily Holmes also wants to take a run-up before jumping on the major questions.  She says: “To dream big and really help people with mental health difficulties, we are going to have to transform our culture … For example, how can we move from studies about ‘description’ (merely counting, describing, knowing if something works or not) to learn to best change what is troubling someone and derive novel interventions to transform mental health?”

But we cannot escape the challenge of the moment. For Tamsin Ford the biggest question for us to address right now is “The impact of Covid and the recession on the mental health and development of children and young people” but perhaps she would say that. Rick Adams is also acutely in tune with the times. When preparing for a scientific lecture, the question at the forefront of his mind is:

“Has someone forgotten to mute themselves?”

Researching student mental health during the pandemic: a PhD student tries to remain objective

Maria Thomas4 May 2020

This blog has been guest written by PhD Student Tayla McCloud, UCL Division of Psychiatry.

Woman anxious at desk with laptop

It is difficult to think of anyone who is unaffected in some way by the current coronavirus pandemic and resulting UK lockdown. Whilst practical adjustments and physical health concerns spring to mind, there are myriad mental health implications, too.

Results from two early online surveys conducted by the mental health charity MQ and the Academy of Medical Sciences (AMS) showed that the main concerns among people with lived experience of a mental illness and others in the general population were the impact of the pandemic on anxiety, isolation, and access to support. These are likely to affect everyone to differing degrees throughout the lockdown.

On April 15th, a team of prominent psychiatric researchers published a piece in Lancet Psychiatry calling for high-quality research monitoring the mental health impact on the general population overall and in specific vulnerable groups. These are defined as including children and young people affected by school closures, older adults who may be isolated, and frontline healthcare workers. This is undoubtedly of utmost importance.

One group also experiencing a lot of disruption, though, is university students. Universities have been forced to close physically, meaning that this year’s exam and graduation season has been upended. Teaching is being conducted remotely and assessments have mostly been moved to different formats online. Like primary and secondary education students, university students will be adjusting to a completely new routine and way of learning.

Unlike primary and secondary students, though, for university students studying ‘at home’ may mean moving back in with parents in a completely different city, town or even country to where they usually study. This is likely to be a considerable upheaval at an already difficult time, with concerns around when it will be safe to return, but students who do not go back to where they lived before university risk being left to live alone without their usual support networks as many others leave.

Most university courses are attempting to continue as close to normal as possible, delivering teaching remotely, which means assessments are still largely going ahead. This means that students are under a lot of pressure to be as productive and focused as usual during what is a very tough time psychologically. Without access to libraries and equipment, they also may not have the resources or study spaces they usually have in which to complete their work. Under-performance, as well as the pandemic itself, could negatively impact their future career.

For these reasons, among others, university students may be at increased risk of experiencing negative mental health consequences of the coronavirus pandemic. It is, however, difficult to know this without relevant data.

SENSE Study Logo

This is where my PhD project, the SENSE study, comes in. SENSE is a longitudinal survey of the mental health of UCL students, conducted online beginning in October 2019. The last wave was in February 2020 and the next wave will begin shortly, in May. It covers such areas as students’ demographics, accommodation, financial situation and social lives, and we are adding new questions relating to the pandemic. This means that we will be able to compare UCL students’ mental health before and during the UK coronavirus outbreak. This could help us to understand more about which groups are more vulnerable to the impact of UCL’s closure and the UK lockdown, potentially highlighting areas for intervention. Follow @SENSEstudy on Twitter for updates, or visit our website www.sensestudy.co.uk.

I am also involved in a new study, You-COPE, which aims to measure the mental health of young people aged 16-24 in the UK throughout the lockdown and public health response and in the months afterwards. Follow me on Twitter (@TaylaMcCloud) for updates on this when it launches. This will include university students as well as non-students, and as such will complement the SENSE data findings and allow comparisons between these two groups.

I am attempting to continue this PhD work as usual, whilst conscious that I am a university student living through the coronavirus pandemic researching the mental health of university students during the coronavirus pandemic. It can be difficult to continue work as a “professional” when your work involves focusing on how students are being negatively affected.

Being a student who is researching student mental health is often quite odd like this. I talk about ‘university students’ in the third person, making hypotheses about this abstract group that it is easy to forget I am part of. I often bring my own university experience into the conversation as an example, as do my supervisors, but I am usually referring to a (somewhat) far away undergraduate version of myself and not my present experience. PhD students occupy a confusing space somewhere between staff and student that means we never quite feel like either.

The current coronavirus pandemic, and the resulting UK lockdown and UCL closure, has undoubtedly impacted my PhD work, as well as seemingly every other aspect of my life. I am trying to use this as an advantage; considering how I can use my experience as a UCL student during this time to inform my research, and my interpretation of the findings of this research. I hope that this will add value to the research I am conducting, and that SENSE and You-COPE will be able to shed new light on our understanding of the mental health of university students at a time when they may be particularly vulnerable.

A PhD student’s experience of the lockdown so far – it’s not all bad!

Maria Thomas27 April 2020

This blog has been guest written by PhD Student Anne Gaule, UCL MRC Doctoral Training Programme in Neuroscience and Mental Health and research student in Department of Clinical, Education and Health Psychology, UCL Psychology and Language Sciences.

school closed sign on school gate

Much like most PhD students I imagine, I followed the news over the last weeks of February closely, wondering how I was going to be able to continue with my research if we entered a lockdown. I am in my third year of the four-year UCL MRC Doctoral Training Programme in Neuroscience and Mental Health. My PhD focuses on social information processing in adolescence, and how this may be affected in children with a history of conduct disorder. This means that a key part of my project is data collection in schools.

At this point I have nearly finished collecting data for one task. I have also been developing new tasks that are engaging and suitable for children whilst having the power required for my stats. Fortunately, (and surprisingly) everything was going according to plan and I was on track to start my piloting and data collection. Unfortunately, I’d planned to start this in March 2020.

For some background, the three new tasks that I have developed need to be run individually with each child at their school and with experimenters present. I have also developed a child version of an adult questionnaire to complement these tasks that needs validation before it can be used. For the new behavioural tasks, I need at least 90 children to take part – on top of piloting.  For the questionnaire, 600 children must take part in order to run full analyses. To submit my thesis by the summer of 2021, I was hoping to have finished collecting data by October 2020 (the optimistic scenario), Christmas at the absolute latest. With around 250 questionnaires completed so far and my new tasks only at the piloting stage, I still have some way to go and the disruption from COVID-19 is putting serious brakes on this process.

My PhD project is a collaboration between our research team and the schools we work with and, as such, it requires time and organisation on both sides. When working with schools, whether mainstream or alternative provision, I am primarily working with teachers who are under an incredible workload. Despite already being overwhelmingly busy, they are generously offering to give up their time in order to help us to carry out this research – which we are all hoping may, in the long run, benefit the children they teach. I am hugely grateful to these teachers and I try my hardest to work around their schedule when setting up recruitment and data collection.

Practically, this translates to a huge number of phone-calls and emails – not to mention keeping track of who you’ve been in contact with and when. We also need consent from parents, which involves the school sending forms and leaving a two-week response period (and getting in touch with busy parents can be as tricky as getting in touch with busy teachers). Once we begin working with a school we need a quiet space on school grounds where we can work with the children relatively undisturbed – not necessarily easy during a busy school day. Finally, testing sessions themselves can also be challenging. We try our hardest to accommodate the children we work with, who are participating entirely voluntarily even if they have parent consent. If a child is having a bad day, we will come back on a different day, or break down the session into smaller sessions. The challenging behaviour of some of the children means the sessions sometimes won’t run smoothly or may take longer than planned. Consequently, an extended period of time has to be factored in for data collection on a project such as this. You can imagine how it felt when, after months of work to set up the data collection operation and with several schools having agreed dates in March for us to work with the children, I then had to cancel all of them. Naturally my anxieties about data collection are not comparable to the impact of this crisis on the schools that we work with – many of whom have vulnerable students whom they continue to support during this crisis. However, it’s hard to see how and when the face-to-face testing can move forward until there is more clarity on when we will emerge from this crisis.

Despite these anxieties, I want to reflect on the fact that I have also been incredibly lucky. I have received a huge amount of support since UCL has closed. For starters, my programme was very quick to notify us that, no matter what stage we are at in our PhD projects, we are all guaranteed an extension of some kind. This has been a huge load off my mind. My supervisor has provided guidance on how to adapt those aspects of my projects that can be conducted online (the questionnaire, for example, is easily transferable) and we have also discussed working on the literature review aspects of my thesis. As all the work I do involves children under the age of 18, whether vulnerable or not, I have had to submit amendments to my ethics in order to adapt various aspects of my data collection – such as taking parental consent online, and recruitment via social media instead of contacting schools directly. Here again I was happy to find that UCL has provided clear guidelines on which projects needed to submit ethics amendments for minor adaptations to protocol for online testing, and the best way to go about doing so. My department has been sending me updates about the UCL’s news and response to the crisis – including specific updates for doctoral students – and also immediately sent us guidance on how to set up to be able to work remotely, so I’ve had continued access to all of my files. My lab has set up regular meetings so that we feel less isolated now that we are no longer to leave our homes.

The immediate support from my programme, department, and supervisor has been a huge relief. I have actually started to enjoy the time I now have to read and to begin writing my thesis. I also believe that as the lockdown conditions ease, I may be able to collect data with the help of other team members, and complete my PhD on time.

Links

National Hospital for Neurology and Neurosurgery: response to the COVID-19 emergency by Jennifer Foley, Edgar Chan, Natasja Van Harskamp & Lisa Cipolotti, UCL Queen Square, London.

tonydavid17 April 2020

The Department of Neuropsychology of the National Hospital for Neurology and Neurosurgery: response to the COVID-19 emergency

  

Jennifer A. Foley, Edgar Chan, Natasja Van Harskamp & Lisa Cipolotti

Department of Neuropsychology, National Hospital for Neurology and Neurosurgery, Queen Square, London.

 

At the time of writing, over 137,000 people worldwide have died with COVID-19 coronavirus. Since the first UK death less than one month ago, almost 13,000 people have now died, with numbers continuing to rise. The UK is in lockdown: ‘non-essential’ businesses and places of worship are closed. Similarly, schools are closed, except for children of key workers. People are only permitted to leave their houses for food, health reasons, one hour of exercise or essential work.

The COVID-19 emergency has required us all to rethink how we work. In the NHS we have had to restructure our clinical services.  At the National Hospital for Neurology and Neurosurgery (NHNN), a leading tertiary referral neuroscience specialist centre in the UK and part of University College London Hospitals NHS Foundation Trust (UCLH), two inpatient wards have been dedicated to COVID-19 patients. In response to the rising bed pressure at UCLH, the Hyper-Acute Stroke Unit has been transferred to the NHNN and a new ‘Emergency Stroke Unit’ created. As a consequence, the discharge of inpatients has been greatly expedited. To prevent the spread of COVID-19, the NHNN has been placed in lockdown; all visitors are prohibited, even for patients who are very sick and dying. Non-urgent outpatient clinics have been cancelled, with those remaining mostly provided by telephone. Outpatients deemed to be ‘extremely vulnerable’ by Public Health England have been advised to shield for 12 weeks and instructed not to leave their houses, even for shopping or medication.

Clinical staff has to work at a quicker pace, in longer shifts and in smaller teams because of increased staff sickness. They must provide more general medicine and have to learn how to use personal protective equipment (PPE). Academic staff has been redeployed clinically and some staff members have been redeployed to the new London NHS Nightingale Hospital. All staff have to work knowing that they might contract COVID-19, potentially placing themselves and their own household at risk.

In response to the COVID-19 emergency and the changes in clinical care at NHNN the Department of Neuropsychology reconsidered its priorities and how best to quickly respond to the new needs. We developed brand new services to support our staff, patients, and families and carers and took urgent action to provide top-class neuropsychological care. Here, we provide a description of how we have achieved this over the past two weeks.

 

The Department of Neuropsychology at NHNN

Neuropsychology is a highly specialised branch of clinical psychology, whose main focus is on addressing fundamental questions about the relationship between brain and mind. We investigate how changes in brain functioning caused by neurological disorder affect how we think and how we behave. Neuropsychologists are not only trained in general mental health, but also have additional qualifications and substantial specialist knowledge in the neurosciences.

The Department is one of the most renowned and prestigious in the world. Each year we treat approximately 6,700 patients. Our main clinical role is in the assessment, management and treatment of patients with complex neurological, neuropsychiatric and neurosurgical conditions. To meet this need, we have developed a flexible, adaptive and rapid neuropsychological assessment protocol, designed for speed of administration, reliability/validity, as well as detecting change from baseline. Our assessment comprises a brief clinical interview and formal evaluation of thinking skills, including general intelligence, memory, language, perception, frontal ‘executive’ functions and speed of information processing, in addition to assessment of mental health. These thinking skills are assessed with tests developed to be reliable, valid and graded in difficulty, and suitable for people of diverse backgrounds and abilities.

We have also developed a wide range of specialised treatment programmes. These mainly focus on group interventions to help patients cope with the neuropsychological sequelae of neurological conditions. We provide strategies to help reduce the impact of deficits of memory, planning, attention and other cognitive impairments on daily living. We also provide one-to-one support to mitigate anxiety and depression, and to support adjustment to the life changes precipitated by a variety of neurological conditions.

The Department plays a role in generating world-class clinical research, publishing approximately 40 peer-reviewed research papers each year. Our research strategy aims to improve diagnostic assessment and further the understanding of brain disorders and cognitive functioning. Recent focus has been on acquiring knowledge to help improve NHS neuropsychological service provision through: development of new tests to allow better identification of frontal executive and nonverbal memory impairments; development of new brief cognitive screening tools; and improved characterisation of the reliability and stability of neuropsychological tests over time, to allow objective monitoring of patients’ thinking skills. We also undertake research addressing questions regarding the neural architecture of cognitive domains, such as frontal executive functions, memory and language, and the characterisation of specific neurological conditions.

Support services for staff

The perceived availability of direct psychological support for staff is crucial for psychological wellbeing in times of crisis (e.g. Khalid et al., 2016). Hence, we have established a psychological support service for all staff. We have developed twice-weekly, face-to-face, walk-in clinics and daily telephone clinics. Our experience, so far, indicates that staff members greatly appreciate our support services. Despite the fact that our services started very recently, we have good intake that continues to increase.

Recent studies emerging from China specifically focusing on the COVID-19 emergency reported that overall there was little uptake of formalised psychological support (Chen et al., 2020; Zhu et al., 2020). It remains unclear what type of support is most effective. Some studies have suggested that it is more helpful to focus on enabling staff members to meet their basic needs: health (adequate PPE), shelter (especially if having to isolate from family members), food and sleep (Chen et al., 2020; Khalid et al., 2016; Khee et al., 2004). Some of these studies have relatively little data (Chen et al., 2020), include few or closed questions (Dai et al., 2020), and/or non-anonymised data collection (Lee et al., 2005; Khee et al., 2004). These factors may somewhat limit the generalizability of their findings. Notably, no formal study has assessed staff members’ psychological needs during crisis in the UK. Therefore, we have developed an online survey to assess staff members’ distress and psychological needs, including access to basic provisions and usual coping strategies, as well as desire for informal or formal psychological support. The data will help us refine our support service response and inform future practice.

Neuropsychological services for inpatients

The Department has developed a highly specialised service to meet the demands of the increased number of acute stroke and neurosurgical inpatients within the time constraints of a very fast medical environment. We continue to provide comprehensive cognitive assessment where necessary, while also adopting a briefer specialist assessment model that draws upon previous work (e.g. Chan et al., 2019). In addition, we have developed a fast-turnaround reporting system to support early discharge and strengthened our work with multi-disciplinary teams to provide support for complex cognitive and behavioural difficulties. The quick discharge of patients with significant cognitive impairment has resulted in patients receiving only minimal rehabilitation in hospital. To support rehabilitation planning, we have focussed on building stronger links and outreaching to community services and relevant charity organizations such as Stroke Association.

Neuropsychological services for outpatients

Outpatient diagnostic services have been significantly delayed resulting in reduced care for patients with chronic and life-limiting neurological conditions. However, acknowledging that some assessments remain essential even during these times, we are continuing to provide face-to-face outpatient cognitive assessments for all urgent cases, with both clinicians and patients wearing PPE. We have deemed this to be necessary given the limited empirical evidence for either the validity or utility of diagnostic tele-neuropsychology (e.g. Bunnage et al., 2020).

For outpatients who have little social contact, isolation and delayed clinical care threatens to create a pandemic of loneliness (Armitage & Nellums, 2020; Van Bavel et al., In Press). The impact of this, exacerbated by increased exposure to negative framing within the media, will heighten stress responses. This may have a potential catastrophic impact upon mental health outcomes (Garfin et al., 2020). As far as we are aware, there are no evidence-based guidelines on how to manage patients’ distress at this time. Nonetheless, it is clear that patients need to be supported. Hence, we are offering all patients offered a rescheduled neuropsychological outpatient appointment a telephone consultation for interim psychological support. To relieve the burden upon already stretched clinical nurse specialists, GPs, community teams and voluntary sector helplines, we have also extended this service to all of the NHNN outpatients and stroke patients within North Central London.

Furthermore, those who had psychological difficulties before the current COVID-19 crisis are most vulnerable to exacerbated distress (Duan & Zhu, 2020). Therefore, we have not stopped any ongoing neuropsychological therapies and continue to accept all new routine referrals for ongoing psychological support. These appointments have now been converted to telephone clinics.

Support services for patients’ families and carers

For family members of inpatients with neurological conditions and/or COVID-19, we have started providing telephone consultations. For families and carers of stroke and neurosurgical patients, we have developed telephone psychoeducation about cognitive and emotional sequelae, and signposting for any ongoing needs.

Conclusion

In sum, we hope that our new support services not only contain and mitigate psychological distress, but also will allow us to research the psychological needs of staff, patients, their families and carers. By redesigning our existing neuropsychological services, we do not delay, but instead respond rapidly to the significant changes and increased demands caused by the COVID-19 emergency. These new services may be helpful in providing empirical evidence to determine which interventions are most useful. This will in turn inform future guidelines, should we have to face a resurgence of COVID-19 or another pandemic.

References

Armitage, R. & Nellums, L.B. (2020). COVID-19 and the consequences of isolating the elderly. The Lancet. Public Health; Mar 20.

Bunnage, M., Evans, J., Wright, I., Thomas, S., Vargha-Khadem, F., Poz, R., Wilson, C & Moore, P (2020). Division of Neuropsychology Professional Standards Unit Guidelines to colleagues on the use of Tele-neuropsychology. Division of Neuropsychology, British Psychological Society; Apr 20.

Chan, E., Garritsen, E., Altendorff, S., Turner, D., Simister, R., Werring, D. J., & Cipolotti, L. (2019). Additional Queen Square (QS) screening items improve the test accuracy of the Montreal Cognitive Assessment (MoCA) after acute stroke. Journal of the Neurological Sciences, 407, 116442.

Chen, Q., Liang, M., Li, Y., Guo, J., Fei, D., Wang, L., He, L., Sheng, C., Cai, Y., Li, X. & Wang, J.(2020). Mental health care for medical staff in China during the COVID-19 outbreak. The Lancet Psychiatry, 7, e15-e16.

Dai, Y., Hu, G., Xiong, H., Qiu, H. & Yuan, X. (2020). Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak on healthcare workers in China. medRxiv.

Duan, L. & Zhu, G. (2020). Psychological interventions for people affected by the COVID-19 epidemic. The Lancet Psychiatry, 7, 300-302.

Garfin, D. R., Silver, R. C., & Holman, E. A. (2020). The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure. Health Psychology; Mar 23.

Khalid, I., Khalid, T. J., Qabajah, M. R., Barnard, A. G. & Qushmaq, I. A. (2016). Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clinical Medicine & Research, 14, 7-14.

Khee, K. S., Lee, L. B., Chai, O. T., Loong, C. K., Ming, C. W., & Kheng, T. H. (2004). The psychological impact of SARS on health care providers. Critical Care and Shock, 100-106.

Lee, S. H., Juang, Y. Y., Su, Y. J., Lee, H. L., Lin, Y. H., & Chao, C. C. (2005). Facing SARS: psychological impacts on SARS team nurses and psychiatric services in a Taiwan general hospital. General Hospital Psychiatry, 27, 352-358.

Van Bavel, J. J., Boggio, P., Capraro, V., Cichocka, A., Cikara, M., Crockett, M., Crum, A., Douglas, K., Druckman, J., Drury, J. & Ellemers, N. (In Press). Using social and behavioural science to support COVID-19 pandemic response. Nature Human Behavior.

Zhu, Z., Xu, S., Wang, H., Liu, Z., Wu, J., Li, G., Miao, J., Zhang, C., Yang, Y., Sun, W. & Zhu, S. (2020). COVID-19 in Wuhan: Immediate Psychological Impact on 5062 Health Workers. medRxiv.

 

Call the Psychiatrists?

tonydavid15 April 2020

Call the psychiatrists?

Stereotypes abound regarding different medical specialists and their personalities. From aggressive, macho surgeons, nice-but-dim GPs to the mad-as-their-patients psychiatrists. The coronavirus outbreak has thrown other specialists into the spotlight. Critical care doctors are a new breed. Not selected for their bedside manner – their patients are usually anaesthetised. They are particularly skilled applied physiologists who understand oxygen saturation. In other words, a bit nerdy. Who knew they were brave too? The academic discipline of epidemiology – tired of explaining that theirs is the study of diseases in populations not ‘epidemics’, this is their moment to prove they have the statistical smarts to interpret the data, discern the trends and test the advice. Ironically, until COVID-19, public health specialists were perhaps the most beleaguered of all the non-coal face doctors practicing in the UK with large cuts to their budgets in recent years. Now they are effectively in charge with politicians supposedly following their advice to the letter. Even within that group’s medical specialism, the tide had long since turned away from infectious diseases – which normally account for a fraction of deaths in high income countries – towards ‘non-communicable diseases’: neurodegenerative conditions like Alzheimer’s, diabetes, heart disease, stroke, cancer, which are fast becoming the scourge of lower and middle income countries too.

Redeployment of ‘rear-guard’ staff to the frontlines followed by recall of retired healthcare workers to help with NHS cope with COVID-19 led to some amusing memes. The first was the blue woolly bespectacled face of Dr Grover being drafted in from Sesame Street to the ITU with the caption ‘stay home unless you want to be intubated by a psychiatrist’ and then Dad’s Army characters – ‘Don’t worry chaps, backup is coming’ with their pompous but insecure leader Capt. Mainwaring representing psychiatry.

We have all been asked to consider our mental health and offered myriad ways to preserve it during lockdown and social isolation. Much of the advice from the NHS has been reassuringly commonsensical and has pointed toward self-help and online resources.  Do psychiatrists have particular role to play?

The biological effects of SARS-CoV-2 on the nervous system are not well understood. Experience from China does not suggest that we should anticipate cases of encephalitis and its inevitable neuropsychiatric manifestations as a result of direct infection of the brain in cases of COVID-19 but vigilance is required. The virus has been detected in the central nervous system in people with severe multi-organ disease. Common symptoms such as dizziness and headache and loss of smell and taste are best not seen as brain-based but rather general indicators of systemic unwellness and upper respiratory tract inflammation. The Association of British Neurologists is setting up a system to collate cases of suspected neurological COVID-19 and clinical neuropsychiatry colleagues from Edinburgh to Exeter have offered to help.

Experts interpret the life-threatening pneumonitis of the disease as a consequence of an all-out immunological response to the infection rather than the infection alone – it seems Boris Johnson dodged that particular bullet – and neurology textbooks have whole chapters on immune-mediated ‘post-infectious’ syndromes. But the contrast with a truly neurotropic virus such as polio which preferentially attacks motor nerve cell bodies could not be more stark. Some will remember the paralysing fear of paralysis which gripped families in the 1950’s and the dreaded spectre of the clumsy ventilators of the time – iron lungs.

The likely legacy of SARS, MERS and now COVID-19 includes psychiatric fall out. In those earlier epidemics, there were high rates of anxiety, depression and PTSD in the short term – although such outcomes never affected the majority. We know about them because people who recovered from infections serious enough to require hospitalisation were asked to fill out questionnaires on their experiences as part of simple research surveys. Few of the studies had controls groups which would allow us to conclude whether such rates were particularly high or not. PTSD is a strange one in this context. Not that being rushed to hospital and seeing the person in the next bed gasping for air and perhaps eventually succumbing, isn’t horrific and likely to etch itself on your memory. And the scene may come back to haunt you as intrusive memories and invade your sleep. But is it really best considered a direct consequence – part and parcel – of your own illness given that your sole allowable visitor, uninfected by the virus, might have been similarly traumatised?

If there are any lessons from psychiatry at times like this is it is to hang on to a kind of natural and shared immunity which we may find deeply embedded within. Natural in the sense of non-technical. Several studies on ‘psychological debriefing’ after traumatic events, have shown that, not only does this not help it makes the situation worse. Perhaps it derails the natural processes – biological, psychological and social – that have evolved to deal with major adverse events. By ‘medicalising’ the process, however unwittingly, it seems that we expose people to more harm rather than inoculating them against it. Hence the UK wide Royal College of Psychiatrists’ sensible advice to resist the temptation to offer such services to colleagues in the frontline. We don’t need the argot of traumatisation and therapy to speak to each other of loss, or bereavement and the yearning for physical contact. Those in the frontline don’t need someone to encourage them to emote in a certain way, to list the pain and guilt, the numbness or indeed the quiet victories. They do need a good night’s sleep, personal protection, reassurance that their efforts are appreciated and the above all the chance to share and fashion stories with each other.

The urge to ‘do something’ is strong and many of my senior colleagues feel at best side-lined and at worst, guilty for not practicing physical medicine. But there is plenty for us to do. Accident and emergency departments still attract a steady stream of people whose repertoire of coping with distress is limited to stereotyped and concrete demonstrations through the medium of physical self-harm. It is expecting too much of them that they will find more adaptive ways of dealing with it at the moment. It’s difficult enough for professionals to find the right words for them, or indeed any words but we are best placed to try. Suicide – since it was first studied by Emil Durkheim in the 1890s – tends to fall at times of national crisis like war perhaps because of an enhanced sense of collective solidarity. Let’s hope that applies to this pandemic. Then there are those with serious and enduring mental illnesses – such as schizophrenia. Perhaps half a million of them in the UK, living in sheltered accommodation, hostels and bedsits, if they’re lucky. People for whom companionship and intimacy are seldom seen as unalloyed good but often as harbouring threat. Social isolation for them is the default. If you live in a world where, at the best of times, religion, TV, and the internet rather than a comfort or distraction, seem arranged to undermine your sense of self, imagine what it’s like to be in the midst of a pandemic caused by invisible lethal particles invading your body  – and your mind – where everyone is a bit paranoid.  When AIDS was much more of a pre-occupation than it is today, one of my patients described how her longstanding nemesis, the persecutory voice that followed her every thought, announced that he was suffering from the virus ‘himself’. Eventually the voice, that personification of threat, succumbed to the disease and fell silent. My patient enjoyed a few days of blissful respite until the virus in a final posthumous category-defying leap, infected her too, at least that was her conviction. Such people are our responsibility and they need our arm’s length support not to mention maintenance medication.

For those feeling under pressure to play a more active role, the Hippocratic dictum: ‘first do no harm’ is worth remembering. I was required to take a version of the hippocractic oath when I qualified, and it always seemed to me to be a low bar and dead-weight to idealism and ambition. But now it seems aspirational. Colleagues in behavioural science struggled to come up with a useful ploy to get people to stop touching their faces; it’s not as easy as you think. ‘Sit on your hands’ was what they settled upon. Good advice all round.

 

14th April 2020, London.

 

Professor Anthony David, is Director of the UCL Institute of Mental Health and author of “Into the Abyss: a neuropsychiatrist’s notes on troubled minds.” Oneworld Publications.