Blog post by Christian Dalton-Locke
On 10 December 2020, the NIHR Mental Health Policy Research Unit (MHPRU) hosted a Zoom event to present research on the impact of COVID-19 on mental health care and discuss future research priorities. It was attended by over 100 people with a range of perspectives, including academic researchers, clinicians, and people with lived experience. Throughout this article are links to the relevant published papers, presentation slides, and recorded videos from the event.
- The policy context
Prof Kendall also told us a bit about what’s happened in mental health services during the pandemic. Referrals to all types of mental health services sharply decreased after the first lockdown in England was announced in March 2020. For example, the Improving Access to Psychological Therapies (IAPT) programme, designed to deliver talking therapies to adults with depression and anxiety in England, saw a drop from over 35,000 to 10,000 referrals a week. Although some services still see people face-to-face in line with the current social distancing measures, many, have shifted almost entirely to online and phone or video calls. This shift towards ’tele-mental health’ is something which came up throughout the event. A recording of the full presentation by Prof Kendall can be viewed here.
- Impact on services and people using them - MHPRU Research
Christian Dalton-Locke, Luke Sheridan Rains, and Norha Vera San Juan, researchers for the Mental Health Policy Research Unit, talked about two studies which investigated the early impact of the pandemic on mental health care: a summary synthesis of 872 articles from 28 different countries and an online UK survey of 2,180 staff working in settings across mental health care. The literature summary included any type of article that discussed impact of COVID-19 on services and people using them, if it was published before 30 April 2020. The survey launched 22nd April and closed 12th May 2020, and asked staff a variety of questions about how the pandemic was affecting mental health care and the service they see.
Issues relating to infection control were often top concerns for staff in inpatient and residential settings. In community settings, staff had sometimes struggled with rapid and widespread service changes to try to cope with the pandemic. They told us that major problems for people using their services include loneliness, social isolation, and increased risks due to domestic violence or inadequate housing. Service users themselves reported deterioration in mental health, especially in depression, anxiety, obsessive compulsive behaviours and eating disorders. The pandemic disrupted their usual routines, activities and relationships which usually enabled people to manage their mental health. However, there were also reports of resilience, feeling better understood by others and effective peer support. In a similarly positive vein, many staff said there were changes made during the pandemic which they wished could be kept retained long term, such as reduced bureaucracy and more flexible working.
A segment of the presentation, where Norha summarises the main results and goes over some of the strengths and weaknesses from both studies, can be viewed here. The full set of presentation slides are available, and for even more detail, both studies have been published in scientific peer reviewed journals (summary of international articles and staff survey).
Ceri Dare, a researcher with lived experience, presented another MHPRU project which involved interviews with 49 service users about their experiences during the pandemic. Ceri explained how some participants spoke about how they had lost their usual forms of face-to-face support from services and were instead receiving their support online. Some felt they were able to engage with remote support quite well, but others found it more difficult. Some described disabilities that affected their use of technology. Others had limited access to technology because of limited finances, or because they lived in overcrowded homes with no privacy. Others simply found it very hard to feel as connected with staff on a phone or video call as they would face to face. Amongst these findings were signs that inequalities which existed before the pandemic had got worse.
You can see Ceri talking about the results from this study here. The study is currently available as a pre-print, which means it has not yet gone through the process of peer review but the full details of it are still available.
- Tele-mental health
Professor Sonia Johnson, Consultant Psychiatrist and Director of the MHPRU, presented findings from the MHPRU studies which specifically related to tele-mental health. There were pros and cons to the rapid and widespread introduction of this way of working in mental health care, both from the perspective of service users and staff. It meant that services were able to continue providing some form of support during the pandemic where otherwise they may not have been able to, but there were concerns of making inequalities worse through digital exclusion. However, some felt it improved accessibility, especially for people who find it difficult to travel. Staff also thought it was more efficient, time saving, and may reduce the service’s impact on the environment. There were also benefits in facilitating meeting across teams and between staff who were working from home or at the office, but there was variation between individuals and organisations in their willingness and confidence in engaging with the necessary technology. Although some service users were content in engaging with care remotely, others experienced it as alienating and intrusive. It seems like the experience of replacing face to face support with tele-mental health is very individual and working out who it works for and in which situations is going to be crucial going forward.
From studies pre-Covid, there is some evidence which suggests remote working can be effective in mental health care, and that most people find video calls an acceptable form of treatment. But these studies were looking at carefully designed and often quite small trials where people had consented to using this type of technology in their treatment. Not widespread and rapid implementation following little or no staff training. Prof Johnson talking about the pros and cons of tele-mental health found from the MHPRU studies can be viewed here. Her full set of slides are available.
- Service activity and mortality
Professor Rob Stewart from King’s College London (KCL) presented findings from a series of studies using electronic health records from South London and Maudsley NHS Trust (SLaM). Unfortunately, they found there had been an increase of around 1,100 deaths amongst SLaM patients in 2020 compared to 2019. This is a bigger increase in the death rate than has occurred in the general population nationally. It was seen in under 65s as well as over 65s, and was more pronounced in some ethnic groups, particularly in Black African and Caribbean groups. Echoing previous talks, Prof Stewart presented results showing that since the start of the pandemic, a lot more clinical appointments are carried out online or by phone rather than in person. Slides from the presentation are available here. Rob’s presentation was based on several studies by him and his team at KCL, all of which are available as pre-prints.
- Community and user-led support
Mark Brown, who is involved with the National Survivor User Network (NSUN), writes about mental health from the perspective of someone with lived experience, specialising in new approaches and social innovations. Central to Mark’s presentation was the idea that there is not a single story that can describe how the pandemic has affected an individual’s mental health. The changes to mental health care since March are unparalleled, and as a result we have lost one of our most treasured tools in promoting mental health: face-to-face communication and human contact. However, between April and July, the NSUN COVID Fund distributed £120,000 to 88 service user led groups and organisations in England to support people with mental health problems during the pandemic and beyond. This includes supporting people to access technology that is required now to engage with most forms of support. You can see Mark talk about the type of activities which were funded here. The Fund is now closed but more detail about it can be found here.
Prof Sonia Johnson, Prof Rob Stewart, and Mark Brown were on the discussion panel, alongside Raza Griffiths (researcher with lived experience and member of the MHPRU Lived Experience Working Group), and Helen Gilburt (King’s Fund Policy Team). A range of topics important to the current mental health research landscape were raised and discussed, covering such issues as BAME representation, the needs of people with intellectual difficulties, the challenges of conducting research at pace whilst maintaining high quality and ethical standards, the shortcomings of the peer review approach to publishing research in a timely fashion, and how COVID-19 has highlighted the pre-existing inequalities in society. The recording of this discussion panel is available here.
- Priorities for future research
We split into themed breakout rooms to discuss priority questions for future research. Here are the ten main questions which came out of these discussions:
- What health inequalities are there now in mental health care, especially with regards to minority or marginalised groups, and how could they be addressed?
- How has the accessibility of services been affected? What are the barriers to use for marginalised/minority groups?
- What is the impact of COVID-19 on needs for community mental health care (including acute/crisis care) and how should these be met?
- What are the social and economic impacts of the pandemic on people with mental health problems and their families, and how could they be managed?
- How can NHS care be made more integrated with voluntary/charity and other sectors to deliver mental health support in times of high demand?
- How have the needs of children and young people been affected by the pandemic, and how can these be addressed?
- What is the impact of loneliness and isolation on people, and how can isolated people be supported?
- What are the current issues with the widespread adoption of tele-mental health and how can services optimise their use of it?
- What is the impact of the pandemic on inpatient and Mental Health Act 1983 use and what strategies could help manage these?
- What is the impact of COVID-19 on mental health (general population and service user), and how can this be addressed?
There were many other suggestions which would address important areas of research on the impact of COVID-19 on mental health care. Here is a full list of the suggestions which were put forward in addition to the questions above:
- How do we hear about the perspectives of people who have “no voice”, such as those who haven’t been assessed?
- What are the issues for people living in spaces which they don’t feel are safe, such as living with domestic abuse or having no privacy and concerns about being overheard?
- What can people receiving services do to re-claim their own space after services stop?
- What has the impact of the pandemic been on those with a learning disability/other disorders such as Autism Spectrum Disorder/migrants and refugees?
- What’s the plan for communities with non-existent mental health care systems?
- Why are there no appropriate therapeutic interventions for BAME patients in community settings? Why is there limited evidence about the perspectives from BAME groups?
- What are the impacts of community mental health services refusing to provide in-person care during this time?
- Has the amount of care to people already using community mental health service pre-pandemic reduced? What is the impact of this?
- Has the pandemic accelerated existing trends in community mental health care regarding reduced services, such as cuts in drop-in social spaces?
- Are there any good practice standards for managers organising services during the pandemic? What does good management look like in a unique, fast-changing situation?
- What is the impact on informal caregivers in how they support their loved ones during the pandemic?
- What are the long-term effects on mental health for those who have been pushed into poverty as a result of the pandemic?
- Why does funding tend to go to large organisations, and not the small, specialised ones that support the most vulnerable?
- Are start-ups, that were created as a result of the pandemic, enough to bridge the gap between access and demand of mental health care?
- How can the third sector best support those with mental health difficulties during the pandemic?
- What has been the role of peer support during COVID-19? How do we encourage peer support to be both effective and valued/supported?
- What are the long-term effects of isolation on children and young people’s developmental milestones?
- What services were provided for young people suffering with mental health during the pandemic and to what extent, were these effective?
- What research has been done to look at fully digital therapeutic options (i.e. backed by RCT’s) in mental health to improve immediate access to high quality mental health resources as a potential bridge to traditional care or an option of care that might work best for some groups of people?
- The reliance of digital technologies during COVID-19 could be a cause of greater health inequality – how can we avoid this and improve access?
- If people had the choice between face-to-face appointments and remote appointments, which would most prefer and why?
- What is the impact of the pandemic on specialist/longer term inpatient units?
- Is there any data about the levels of detention in hospital for people with mental health difficulties during the pandemic?
- What is the trust-level variation in inpatient bed use during COVID-19 and how has it affected patient outcomes?
- What has been the impact of COVID-19 on restrictive practices in inpatient settings?
- What will be the mental health impacts of long COVID-19, both in service users and the general population?
- What has happened to suicide rates during COVID-19?
- What are the enablers and barriers to people engaging with mental health support online? There are home environments which are not conducive to therapy, such as single parents with children at home and people living with domestic violence. Whereas there may be other situations where people prefer online contact to face to face, because for example, they don’t have to travel.
- How does engaging in support/therapy online and at home affects how the person receiving support feel about their home environment? One of the benefits of going somewhere for therapy/support is that you can ‘dump’ everything there and then return home. Are service users able to reclaim their home space following the online session? Are there some things than can help with this such as going for a walk afterwards?
Our event highlighted a lot of rapidly conducted research which has helped us to understand the impacts of the pandemic on mental health services and service users, and what might be the most helpful responses to the challenges it has created. Our event also showed there is much more to do. We will share our list of priorities for research with policy makers through our MHPRU networks. We hope it also encourages discussion. If you are doing work to address any of these important issues, we would be pleased to hear from you.
You can get in contact with us by email: firstname.lastname@example.org or via Twitter: @MentalHealthPRU
This blog reports an event organised by the NIHR Mental Health Policy Research Unit, which is funded by the National Institute for Health Research Policy Research Programme. The views expressed here are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health and Social Care or its arm's length bodies, and other Government Departments.