In this brief commentary, Dalton and colleagues (2020) set out the rationale for providing and prioritising communication with young people about the Covid-19 pandemic. Sensitive and age-appropriate conversations about life-threatening illness have a known positive impact on young people’s long-term well-being. When accurate and transparent information on changes within the family is missing, children may try to make sense of circumstances on their own. But, inaccurate or partial knowledge can lead to excessively negative interpretations of the pandemic and the family situation. The authors also argue that children and young people are highly attuned to their carer’s mental states. Thus, being exposed to behaviours and emotions that may seem unexplained or unpredictable, may increase young people’s anxiety and sense of threat. Conversely, unfiltered and age-inappropriate communication may lead to self-blame or unrealistic feelings. For instance, a young child may believe that an illness is a punishment for previous bad behaviour. Also, an absence of emotion-focused conversations might leave children anxious about the emotional state of the adults around them. This anxiety can result in children’s avoidance of voicing their worries, leaving children to cope with difficult feelings alone. The authors, therefore, recommend that adults should be honest about some of the uncertainty and threat posed by the pandemic without overwhelming young people with their fears. This authentic stance offers a coherent narrative for what young people are observing while also opening the space for talking about their own emotions and thoughts.
COVID-19 | 2020 Research Round Up
Read cutting edge research on trauma and childhood maltreatment related to Covid-19 published during the first two quarters of 2020.
1. Protecting the psychological health of children through effective communication about Covid-19
This brief commentary sets out the rationale for providing and prioritising communication with young people about the Covid-19 pandemic.
2. Cognitive therapy for posttraumatic stress disorder following critical illness and intensive care unit (ICU) admission
A detailed guideline on how to adapt an evidence-based psychological treatment for PTSD, based on Ehlers and Clark’s (2000) cognitive model trauma, to patients with post-ICU PTSD.
In this recent paper, Murray and colleagues (2020) provide a detailed guideline on how to adapt an evidence-based psychological treatment for PTSD, based on Ehlers and Clark’s (2000) cognitive model trauma, to patients with post-ICU PTSD. Following admissions in ICUs, a substantial minority of patients develop psychological difficulties in the weeks and months after discharge, including post-traumatic stress disorder (PTSD). The sharp increase in ICU admissions during the covid-19 pandemic may lead to an increase in patients presenting with PTSD symptoms related to their experiences of illness and medical treatment. It is paramount that health professionals can recognise, understand and address traumarelated symptoms following admission to ICUs. The authors provide examples and treatment strategies in line with the three central aims of cognitive therapy for PTSD: i) to modify threatening appraisals (personal meanings) of the trauma and its consequences; ii) to reduce re-experiencing symptoms by elaborating the trauma memory and by breaking the association between everyday stimuli and trauma memory (then vs now trigger discrimination training); iii) to reduce avoidant cognitive and behavioural strategies that maintain a sense of current threat.
Murray, H., Grey, N., Wild, J., Warnock-Parkes, E., Kerr, A., Clark, D. M., & Ehlers, A. (2020) Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission. The Cognitive Behaviour Therapist, 1-36. DOI: https://doi.org/10.1017/S1754470X2000015X
3. Experiences of acute Covid-19 symptoms can be traumatic and lead some to develop posttraumatic stress disorder
The the findings of this study suggest that experiencing acute Covid-19 symptoms can be traumatic and that a substantial minority of individuals will likely develop PTSD.
In this study, Bo and colleagues (2020) used the amended self-reported post-traumatic stress disorder (PTSD) checklist – civilian version (PCL-C) to assess the severity of PTSD symptoms among hospitalised Covid-19 clinically stable patients before discharge. Among the 714 recruited patients, the vast majority (96.2%) reported significant traumatic stress symptoms. Yet only half (49.6%) of the patients held positive attitudes toward online crisis mental health services. During previous influenza epidemics, such as SARS, the prevalence of PTSD among survivors was 9.79% in their early recovery phase. So, it is likely that during the recovery phase the prevalence of individuals who will meet criteria for PTSD may be lower. Even so, the findings of this study suggest that experiencing acute Covid-19 symptoms can be traumatic and that a substantial minority of individuals will likely develop PTSD. The authors recommend appropriate psychological interventions and long-term monitoring for hospitalised Covid-19 patients.
Bo, H., Li, W., Yang, Y., Wang, Y., Zhang, Q., Cheung, T., … Xiang, Y. (2020). Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. Psychological medicine, 1-7. doi: 10.1017/S0033291720000999
4. Advantages, disadvantages, and applications to practice for adverse childhood experience (ACE) scores
A description of how primary mental-health services, such as IAPT in the UK, may adapt to support frontline professionals’ well-being in the short- and long-term.
The Covid-19 pandemic is exerting unprecedented pressure on health and social care provisions. As a result, health-care professionals face unprecedented practical and emotional challenges. Cole and colleagues (2020) describe how primary mental-health services, such as IAPT in the UK, may adapt to support frontline professionals’ well-being in the short- and long-term. The authors describe a phased, stepped-care and evidence-based approach recently adopted to support local frontline staff in a London NHS trust. Their model of care was based on three principles: i) cognitive behavioural therapy (CBT) delivered on the stepped-care IAPT model; ii) phased interventions to meet the needs of frontline staff during different stages of the outbreak, iii) adaptations to psychological interventions that take into account social distancing and diversity of NHS staff.
Cole, C., Waterman, S., Stott, J., Saunders, R., Buckman, J., Pilling, S., & Wheatley, J. (2020). Adapting IAPT services to support frontline NHS staff during the Covid-19 Pandemic: The Homerton Covid Psychological Support (HCPS) Pathway. The Cognitive Behaviour Therapist, 13, E12. doi: 10.1017/S1754470X20000148
5. Effectiveness of small group cognitive behavioural therapy for anxiety and depression in Ebola treatment centre staff in Sierra Leone
These findings suggest that group CBT represents a promising psychological intervention to support frontline staff during epidemics.
Cole and colleagues (2020) evaluated the effectiveness of group cognitive behavioural therapy (CBT) for anxiety symptoms and functional impairment among frontline professional during the Ebola outbreak in Sierra Leone. The intervention consisted of eight sessions (of three hours) over six weeks. The sessions covered topics such as behavioural activation; reducing avoidance behaviours; identifying values and generating goals related to these; ways to deal with unhelpful cognitions and thinking patterns; problemsolving skills; and strategies to manage anxiety. Post-intervention, the sample of 253 professionals reported lower symptoms of anxiety, depression and functional impairment. These findings suggest, according to the authors, that group CBT represents a promising psychological intervention to support frontline staff during epidemics.
Cole, C. L., Waterman, S., Hunter, E. C. M., Bell, V., Greenberg, N., Rubin, G. J., & Beck, A. (2020). Effectiveness of small group cognitive behavioural therapy for anxiety and depression in Ebola treatment centre staff in Sierra Leone. International Review of Psychiatry, 1-9. doi: 10.1080/09540261.2020.1750800
6. Factors linked to frontline professionals’ mental health outcomes when treating Covid-19 in China
This study suggests that frontline professionals engaged in the direct diagnosis, treatment, and care of patients with Covid-19 may be at increased risk of developing symptoms of depression, anxiety, insomnia and traumatic stress.
In this cross-sectional survey, Lai and colleagues (2020) explored the prevalence and factors that may be associated with mental health outcomes among frontline professionals in China treating patients with Covid-19. Among the 1257 doctors and nurses, 50.4% reported symptoms of depression, 44.6% of anxiety, 34.0% of insomnia, and 71.5% reported distress. Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe symptoms than other health care workers. Participants from outside Hubei province were associated with lower risk of experiencing symptoms of traumatic stress compared with those in Wuhan. In summary, frontline professionals engaged in the direct diagnosis, treatment, and care of patients with COVID-19 may be at increased risk of developing symptoms of depression, anxiety, insomnia and traumatic stress.
Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., … & Tan, H. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open, 3(3), e203976-e203976. doi:10.1001/jamanetworkopen.2020.3976
7. A longitudinal study on the mental health in the general population during the Covid-19 epidemic in China
This study explored self reported post-traumatic stress (PTSD), anxiety and depression symptoms in the general Chinese population during the initial outbreak and the epidemic’s peak four weeks later.
Wang and colleagues (2020) explored self reported post-traumatic stress (PTSD), anxiety and depression symptoms in the general Chinese population during the initial outbreak and the epidemic’s peak four weeks later. 1304 people completed the survey during the initial outbreak and 861 during the epidemic’s peak (333 people took part in the survey at both time points). During the initial outbreak, moderate-to-severe PTSD symptoms, anxiety and depression were recorded, respectively, among 8.1%, 28.8% and 16.5% of the participants. The researchers found no significant longitudinal changes in these prevalence rates despite a sharp increase in the number of COVID-19 cases. Moreover, this study identified a range of possible protective factors associated with lowered symptoms severity. These included high confidence in doctors, perceived likelihood of survival, low risk of contracting Covid-19, satisfaction with health information and personal precautionary measures.
Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., McIntyre, R. S., … & Ho, C. (2020). A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain, Behavior, and Immunity, 87, 40-48. doi: 10.1016/j.bbi.2020.04.028
8. Child and adolescent mental health amidst emergencies and disasters
This commentary aims to inform best practise in the realms of emergency preparedness, fostering resilience and response/treatment.
Danese and colleagues (2020) argue that the needs of the community can overshadow young people’s mental health at times of emergencies and crises, despite their well-being being often affected the most. Besides suffering traumatic experiences, young people may lose fundamental resilience factors. These include support from carers, family members, friends and the social and statutory infrastructure that, during normal times, monitors and safeguards their well-being and safety. The commentary aims to inform best practise in the realms of emergency preparedness, fostering resilience and response/treatment. Suggested future directions include training staff (before emergencies occur) in the assessment and treatment of trauma-related psychological difficulties, timely screening and coordination with local institutions (e.g. schools), and care provision at different levels (e.g. prevention, acute interventions, long-term monitoring). The authors also highlight practical ways in which childhood and adolescent mental health services (CAMHS) can play a crucial role in mitigating the impact of emergencies and crises among young people.
Danese, A., Smith, P., Chitsabesan, P., & Dubicka, B.(2020). Child and adolescent mental health amidst emergencies and disasters. The British Journal of Psychiatry, 216(3), 159-162. doi: https://doi.org/10.1192/bjp.2019.244
9. Literature review: How to reduce the impact of being quarantined
In this rapid review of the evidence, most reviewed studies reported a negative impact of quarantine on mental health, including symptoms of post-traumatic stress, confusion, and anger.
In this rapid review of the evidence, Brooks and colleagues (2020) identified 24 published studies on the psychological impact of being quarantined (i.e. isolated) because of confirmed or suspected exposure to an infectious agent. Most reviewed studies reported a negative impact of quarantine on mental health, including symptoms of post-traumatic stress, confusion, and anger. The reviewed literature suggested that some of these adverse effects can be long-lasting. Factors identified as possible contributors to reduced mental health included infection fears, longer quarantine duration, frustration, boredom, inadequate information, financial loss, scarce supplies and stigma (i.e. rejection from the local community, family and friendships groups). To reduce the potentially detrimental effects of being quarantined, this review identified a range of possible mitigation measures. First, when quarantine is deemed necessary, health professionals and officials should provide adequate and rapid communication. People who are quarantined need to understand their situation. Second, medical and general (e.g. food) supplies should be provided and guaranteed. Third, the quarantine period should be as short as possible, and the duration should be changed only in extreme circumstances. This is to reduce the sense of uncertainty and unpredictability. Finally, voluntary quarantine is linked to less distress and fewer negative mental health consequences. Therefore, public health officials should highlight the altruistic choice of self/voluntary isolation.
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet 395(10227), 912-920. doi: 10.1016/S0140-6736(20)30460-8
10. Increased risk for family violence during the Covid-19 pandemic
This commentary highlights how social distancing and isolation, despite their public health benefits in the context of the current pandemic, can lead to an increase in family and interpersonal violence.
This commentary by Humphreys and colleagues (2020) highlights how social distancing and isolation, despite their public health benefits in the context of the current pandemic, can lead to an increase in family and interpersonal violence. The authors make recommendations for how clinicians can identify instances of abuse during patient interactions. Such future directions include making violence part of any assessment, enquiring about family stress levels, substance abuse, co-parenting relationships and available support. The authors also developed a set of practical recommendation that clinicians can make to parents. Clinician, for example, can help parents recognise and normalise feelings of anger, stress and irritability associated with the demands posed by childcare. Also, parents can be helped to understand that a surge in children’s challenging behaviours can be a developmentally normative response in the current circumstances. The authors also recommend that the use of consistent routines, including wake-up, bed, and meal times to provide structure for both children and parents.